Notes field

Data Element (edit)
Field Name:	Notes
CCMDB Label:	Notes
CCMDB tab:	Top Row
Table:	L_Log table
Data type:	memo
Length:	not stated
Program:	Med and CC
Created/Raw:	Raw
Start Date:	1988-07-11
End Date:	2300-01-01
Sort Index:	9

Used by data collectors to keep notes during collection.

• SMW

Legacy implementation right in the table

• Cargo

• Categories

• Forms

The notes field expands to a bigger form when you double-click on it.

Usage of the notes field

The notes field was set up to be a free-for-all where collectors can store any info they want. This resulted in non-standardized collection practices which result in problems during vacation coverage or on shared wards.

Guidelines

• Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others.

Patients being sent

• Template:Discussion perhaps tagging things for main office, as indicated below, should be done differently or in different place as notes are difficult to sift through in main office. Some collectors delete notes before they send. Others put no notes. People use non standard abbreviation or own codes which is not clear for main office.
• For patients you are ready to send, make sure you note explanations for data values that you think might cause call-backs from the Data Processor or Statistician. For example:
• Extreme data that was confirmed as correct:
  • extreme physiological APACHE values, eg Sys BP of 50 valid , see APACHE_Scoring_table and APACHE_physiological_variable_collection#Exceptionally_high_or_low_values
  • tasks for renal transplant patients that do not follow the norm

Up-to where/when collection is complete

• STB - where we have left off reading in the EPR notes by entering the date/time last read

Diagnoses or other data that needs to be reviewed or checked

also to state if the diagnosis is not confirmed yet etc.

• diagnosis is still unclear as they are waiting for further tests or results
  • Template:Discussion should such a dx be entered and noted in notes, or not entered until confirmed and tracked in notes instead? Ttenbergen 16:26, 9 November 2010 (CST)
    • this is probably a question for main office, especially now that they use the data before completion. Ttenbergen 14:24, 2014 September 19 (CDT)
      • if data is INCOMPLETE, main does not rely on DX info. If DX has not been confirmed, notes field is good place to put a Clear note to self or to collector who is covering you.Trish Ostryzniuk 17:26, 2017 November 20 (CST)
        • I am not sure that is true, I think Julie uses the Primary Admit Diagnosis even for incomplete patients. Will flag this question for her.

Do you use diagnosis information before patients are complete, e.g. Primary Admit Diagnosis? Yes, I use the primary diagnosis for the reason of readmission even if the record status is incomplete. --JMojica 09:07, 2018 December 6 (CST)

• SMW

• Cargo

• Categories

Supplemental data

• track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.
  • would you not just enter a new line for these, and the date of the new line would tell you how far you got? Ttenbergen 14:24, 2014 September 19 (CDT)

• to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
  • Template:Discussion only useful if we review it as that at main office. most of the dx use there is by filter, so they would never see this. main office: thoughts? Ttenbergen 14:24, 2014 September 19 (CDT)

• to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.

• to define what exactly needs to be entered, when a profile is only partially completed.

Automatic population of notes field for newly entered patients

We tried to standardize field into a kind of form, but collection practice is too non-standard to come up with a format that worked.

Template:Discussion Just being curious if the notes field is a free space for optional additional info....what specific problems did this cause? I actually prefer a blank notes field. The premise was good but turns out to not be all that helpful.--CMarks 11:53, 2018 December 6 (CST) Recently a format was implemented and placed into the notes field. We would like to know if this format is helpful and if you use it. Please indicate here if you use it or not and any comments you would like to make regarding this: Laura: I find the guidelines written in this article are sufficient information for the notes field to give tips for usage. If anyone has difficulty when they are covering for someone else, they just need to ask what is meant by specific entries. I would like to speak to anyone who has difficulty. I feel that the notes section is not only used differently for different collectors but also in different scenarios. I like that it allows for individual needs and allows some freedom for any use that each collector may require. The current format is not user friendly and I just wonder who actually is using it. I personally would prefer a blank note field. --LKolesar 07:49, 2018 December 6 (CST) I too, would just prefer a blank note field. As good as the idea for dates and times was, the format just wasn't what I use. DPageNewton 07:57, 2018 December 6 (CST) I do not find this useful or user friendly. I much prefer a blank field so we can enter what we need. Lois I modify the format to suit my needs, so I am not using it as intended. It is less convenient than how I was writing in date and time read up to before the change was made. Good idea, but didn't quite work for me.Mlagadi 08:25, 2018 December 6 (CST) While I appreciate the intent to assist data collectors with collection, I find the current format not helpful. I agree with Laura regarding data collectors having differing needs/preferences, and the best way to accommodate all data collectors would be a blank notes field Pamela Piche 08:45, 2018 December 6 (CST) I prefer a blank note field Lisa Kaita 09:39, 2018 December 6 (CST) I also prefer the note field to be blank. It takes just a few seconds to erase but it's a few seconds I don't have to spare. --mvpenner 10:29, 2018 December 6 (CST)