Critical Care and Medicine Database Core Curriculum

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This page is part an orientation guide for new collectors. It gives a general overview of the data collection processes for both Medicine and ICU collectors at all sites.

To find instructions and guidelines for specific items try using:


For more specific information see:

Site Specific Collection Details   

Introduction

The Critical Care and Medicine Database collects medical data on patients admitted under the Medicine and Critical Care services at HSC, St. B and GGH.

Medicine and ICU collectors review patient charts (either on EPR or paper copy) and enter data into a CCMDB program on their laptops.

The Patient Record

The fundamental unit of the ICU and Medicine databases is the patient record.

A single profile is created for each patient, every time they are admitted under a new clinical service. For example, a record will be created for each admission to:

  • ICU service: HSC MICU, St.B. ICMS, GGH ICU, etc.
  • Medicine service: HSC A-Medicine, St.B. E-Medicine, etc.
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  • SMW


  • Cargo


  • Categories


Every record contains detailed information about each patient:

Diagnostic Coding

Our database program uses a locally-adapted version of ICD-10 (International Classification of Diseases) to capture the pertinent diagnostic information for each patient.

There are three elements to our coding method:


1. The diagnoses are divided into three “bins”.


2. The diagnostic codes range from very specific to more general.

The goal is to code the most specific diagnosis possible.

If a specific code does not exist, there are many “waste basket” codes that are made for virtually every body system and type of diagnosis.

For example:

  • if the patient presents with a vasculitis, but it’s specific identity is not known, use the more general “waste basket” code Vasculopathy/vasculitis, NOS.

Some other examples:


3. Diagnostic codes can be combined together.

Some diagnoses are combined together by using the same priority number.

Some reasons for such combinations are:

Intervention Coding

Our database program uses a locally-adapted version of CCI (Canadian Classification of Interventions) to capture the interventions/procedures done during the patient’s admission.


1. CCI codes are divided into four categories:

  • Therapeutic interventions: ex. amputation of ischemic limb.
  • Diagnostic interventions: ex. renal biopsy.
  • Obstetrical interventions: ex. induction of labour
  • Imaging interventions: ex. CT head


2. The CCI codes are collected by two methods:

  • The “menu-driven” method, where the body part is combined with the intervention done to it. Ex. (T) Tibia, Fibula + fixation.
  • The “picklist” method, where certain interventions can simply be selected from a list. Ex. Transfusion of PRBC.


3. The CCI codes are divided into two “bins”:

  • Admit CCI’s - procedures done within 48 hours prior to admission.
  • Acquired CCI’s - procedures done during the current admission, listed by date.

Collection Instructions

There are many other details pertaining to all elements of data collection. The following links may be helpful for both ICU and Medicine collectors:

Currently active Tmp projects

 
Alias ID collection
Boarding Loc
Service tmp entry
Transfer Ready DtTm tmp entry

Data collection infrastructure

Administration

Related articles

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