STB Medicine Collection Guide: Difference between revisions
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=== APACHE tab === | === APACHE tab === | ||
To collect the elements of the [[MOST | To collect the elements of the [[MOST]] score, on the Apache tab: | ||
* for patient who come from MICU , look on the the MICU flow sheet | * for patient who come from MICU , look on the the MICU flow sheet | ||
* for all other patient use EPR vital signs | * for all other patient use EPR vital signs | ||
Revision as of 15:23, 1 March 2017
This article contains information specific to STB Medicine, see the Medicine Curriculum for general information, and STB Collection Guide for St Boniface specific information.
Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles.
See also:
Location of information
We use EPR for all Admit/Transfer/Discharge times. ENagy
Off ward field
Full-time off ward patients are captured on the E5 laptop only. Patients whose stay is partly on E6 will be captured on that laptop and have the off ward box checked.
vacation coverage
Vacation relief
- for Elaine, coverage is for E6 and B5
- for Debbie, coverage is for E5
- Is any of this different from Vacation and staff shortage collection priorities? Should it be? Ttenbergen 18:35, 2016 November 10 (CST)
For those collectors who are doing vacation relief for the regular collectors who are away, catch up from time off can be expedited for the returning collector if the following things are prioritized.
- do opp and color generation. ADL's are a component of the opp and can be found on the STB Electronic Patient Record. They are in "initial assessment" form under the documents tab. Everything needed for minimal data will be included if the opp is done.
- medicine apache score. The SBGH ER unit is online with their vital signs and neuro assessment. This means that the vital signs and gcs required for the apache score can now be found under the flow sheets tab. To access neuro check, click on flow sheets, then care and assessment, then neuro. The only exception to this is for patients admitted to the unit from MICU. MICU does not use epr (electronic patient record) for vital signs, and hence apache for these patients still need to be obtained from the paper flow sheet in the chart.
The only things that need to be taken from the paper chart are the dpst info. If the opp is kept current and up to date then charts would not have to be pulled from medical records by the person returning from vacation. This would help tremendously in catching up from time off for the returning collector.DPageNewton 14:40, 2013 February 20 (EST)
items not yet on electronic chart
Overstay Project
SBGH has now gone to paperless charting or STB Electronic Patient Record. This means that we can now review almost the entire chart on the computer. The exceptions to this are:
- the DPST Form. The information found on this form is one part of the information we need for the overstay predictor project (opp).
- The DPST is not being completed on E5 for the last few months. Need to see if the overstay program will be continued or not.--LKolesar 13:28, 2017 February 6 (CST)
APACHE tab
To collect the elements of the MOST score, on the Apache tab:
- for patient who come from MICU , look on the the MICU flow sheet
- for all other patient use EPR vital signs
Lab results
Lab results are now entirely online in the epr.