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
Admission and discharges unit Log book is found at the Unit Ward Clerk Desk.
Ward Contacts
ACCU 235-3843
Fax 235-3848
Rosanne (PTM) 235-2981
Chris (Educator) 235-3997
Helen (Ward Clerk) 235-3843
Collector "base"
Just review the TISS sheets and any paper chart components in CCU or in the charting room on 5A. There is very little space to work in CCU right now, you can ask the ward clerk where you can sit to review the charts. A new CCU is under construction and hopefully this will not be a problem then.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.
- When the new CCU opens (hopefully end of June 2016), it is likely that the patient charting structure will change. This will be updated once we know what the structure will be. We have heard that they will only use the ICU flow sheets and may no longer use the Acute MI care map structure but we will wait and see. --LKolesar 08:51, 2016 June 8 (CDT)
Patient exclusions
Post-Angio
We do not enter patients into the database when the cath lab is recovering patients there (borrowing a bed).These pts are only in CCU for post procedure care after an angio they send the patients to CCU for recovery only when the pre and post angio area is closed, usually in the late evenings and nights.--LKolesar 12:12, 2014 July 25 (CDT)
Elective Cardioversion
When patients come to CCU for an elective cardioversion only, they are not entered into the database. This is also a bed borrow according to Marla Penner. --LKolesar 17:54, 2015 August 18 (CDT)
Paper notation for primary angios
On the paper log sheet in the data collectors' binder, we put a small heart figure in the admit-from space to indicate all patients who come directly from the cath lab. You must also put where the patient was prior to the angio in this space. This includes, but is not limited to, primary angios.
- Primary angio means the patient came directly to the cath lab via EMS or they are first sent to angio before other interventions are done in ER. --LKolesar 12:20, 2014 July 25 (CDT)
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 Coronary stent insertion, then the Myocardial infarction 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 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.