STB ACCU Collection Guide
This article contains collection information specific to the CCU (Cardiac Care Unit) at St Boniface.
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 the following for more general information:
Unit admission log book
Where is it stored, in enough detail that another collector could find it? Template:Discussion Log book is found in CCU where the bedside chart slots are.
Ward contacts
Anyone you need to know about to do your work? Template:Discussion The ward clerk on Days in CCU is Helen, Christine is the Ward clerk on 5ACM
Collector "base"
Where on the unit do you hang out to do your collection? Template:DiscussionJust review the tiss sheets and any paper chart components in CCU or in the charting room on 5A. All other chart information is on EPR which can be reviewed in our office on the computer.
Location of patient chart components
- Most information is on EPR. There still are heart cath reports stored on paper but usually heart caths also are reported on EPR. Echo reports on paper chart.
Charting Note
The CCU patient chart has a flow sheet for the nurses to fill out their vital signs and patient assessments. If the patient has had an acute MI, a care map type of flow sheet is used. This has four steps as the patient progresses in their recovery. A second option for nurses’ charting is a CCU flow sheet for all other types of patients other than acute MI. (examples: arrythmias, pre op optimizations, cardiomyopathy, chest pain NYD, etc. ). Occasionally a COR sheet (like those used on the wards) can be continued in CCU and even the Y2 procedure note page has been continued on a rare occasion for a patient who needs some CCU management post angio.
Post-Angio patients exclusion
We do not collect patients who arrive in CCU for post procedure care post angio only because the pre and post angio area is closed.
Paper notation for primary angios
On the paper log sheet we put a small heart figure to indicate all primary angios in the admit-from space but you also need to put where the patient was just prior, which is also written in this space.
Diagnostic Coding vs Admit-From
Primary angiograms are those that go first to the angio room and then to CCU afterwards. In this case the first admit diagnosis should be angiogram, then angioplasty, then stent, then the MI with location subcode and then other items like CHF or TNK if applicable. The exception to this rule is when the patient has a cardiac arrest before arriving in CCU or has cardiogenic shock. These will then be coded first and then the primary angio sequence. If you are past the quota for number of admit diagnosis codes, you can use only angioplasty if necessary (take out angiogram and stent if needed).
If the patient comes from an ICU (different hospital) do not use the MI as the first diagnosis. Other options could be post infarct angina, unstable angina, chf, cardiogenic shock, etc. The second diagnosis could be the MI.
This needs to go elsewhere
Template:Discussion This is probably not unit specific information so it should be moved to the relevant articles so all collectors will connect it the same, and so that when we look up information about the topic we don't miss anything because it's buried in the site specific info. Could someone please split this out to the relevant articles? I get the feeling one of the collectors would know better what needs to go where, but when it's done this heading/section should be gone.
- Most of the above is a special case of the instructions in Admit Diagnosis. I think that doesn't even need to be transferred.
- Some more of it is specific to Angioplasty or [[Angiogram]