Notes field

There is a Notes field on the laptop and in the CCMDB.mdb. This field is for notes during collection only. The notes field expands to a bigger form when you double-click on it

The contents of the notes field are not sent in to the Regional Server with the patient data files. Notes are not stored in TMSX or MedTMS.

Usage of the notes field

Template:Discussion It was suggested in Requested_CCMDB_changes_for_the_next_version#Notes_field that we might be able to use the notes section on the laptops to keep track of things currently done in paper.

Norine and Jackie at the Vic have been using this field for just that for a long time, and I think their insight could be helpful to others.

However, if this field were to be more commonly used, it would be good if everyone used it in a similar way so it would work for hand-over during vacation or similar just as well as for keeping track for yourself.

You collectors know best what would be helpful. Could you comment on what sort of things you keep track of that this might be helpful for, and what might be a good protocol to do this? As part of this it would be good to know how you keep track of how far you got in a chart, and whatever else a different collector would need to know to finish of a patient you started. I will start a list below here, but free-flow comments are invited as well!

List

• diagnosis is still unclear as they are waiting for further tests or results
• where we have left off & also to state if the diagnosis is not confirmed yet etc.
• track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.
• to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
• 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.

Discussion

Any other comments? Ttenbergen 16:18, 16 April 2010 (CDT)

• It's interesting that you'd like to know what method I use to keep track of how far I have gotten in a chart when doing reviews, since there has been a bit of controversy just this morning from one of our doc's regarding this very issue. It has been my practice to make a small mark with a yellow highlighter in the margin of the ipn (integrated progress notes) notes, at the last note that I have read. The next time I go back to review the chart, I look for the yellow highlighter mark. I have now had two of our doc's complain about the tiny unobtrusive mark. Any other suggestions that can be used that will keep our doc's happy, would be much appreciated. Thanks. DPageNewton 17:46, 28 September 2010 (CDT)

• • If the note field is now "readable" by Pagasa could this note field be used to report/confirm an extreme Apache lab or vital signs value was entered and what that value was? Mlaporte 22:20, 3 November 2010 (CDT)
    • I think it is very appropriate to put things that are outside the norm in the note field.--CMarks 08:16, 4 November 2010 (CDT)
      • I think it would reduce emails and pulling charts if the extreme value or outlier was confirmed in the note field prior to sending. Outliers that are entered without a note would of course require follow-up.Mlaporte 19:11, 4 November 2010 (CDT)

Apache secondary upper and lower limits

• • • • for APACHE, we are going to put "some" other upper and lower limits in Access so that Access will ask a collector, before sending, to "verify" that the value entered is correct even though it outside the norm. Julie is going to look at the database and advise what these limits will be. We are trying to reduce some of the questions that Pagasa has to ask collectors about odd APACHE values, values that are "possible" but not very "common".
      • Example, if WBC is recorded as 150 or > then Access will ask you if you are certain that value is correct. You will have the chance to "correct it" or "accept" it as correct. Pagasa will no longer have ask collectors about these "uncommon" values. If they have passed through to her, it is understood that Access has already made the collector "verified" that the uncommon value is correct before it was sent in.--TOstryzniuk 17:56, 5 November 2010 (CDT)