HSC Medicine Collection Guide

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This will serve as a reference for any collector who is assigned or choices to pick up extra hours during sick or vacation at this site.

If you want to see current guideline for sites go to: Medicine Curriculum or ICU Curriculum and look at top of this article to find link to hosp/unit specific guideline in progress.--Thanks everyone.TOstryzniuk 20:18, 21 October 2010 (CDT)

wards

Medicine Database for CCMDB is collected on six medical wards at HSC including following any admissions in other areas/wards in the hospital that are under Medicine service attending physician's care.

  1. A4
  2. B3
  3. D4
  4. D5
  5. H4
  6. H4H - HOBS - High Observation Unit (labeled by cubicles)


We collect data on all patients admitted to these wards including teaching,non-teaching and off service. For example neuro medicine patients are included. Another example renal patients under nephrology are included.

Discussion

  • HSC medicine data collectors, can you please clarify. At the beginning of this article is say that HSC medicine includes neuro, oncology and rehab patient. It says that we collect all teaching and non teaching patient to medicine wards and include neurology patient, yet for H733,(contingency beds section) it say we DO NOT include neurolgy, oncology etc patients? I highlighed in bold discrepancy above once sorted out, I will move above contingency bed information to HSC contingency bed article. thanks--TOstryzniuk 17:54, 18 January 2011 (CST)

This is correct Trish we do not collect data on neuro patients on the non-teaching units unless they have been accepted by a medicine service. The same rule would apply for another service that might get into the non-teaching unit but had not been accepted to medicine. This is not true on the wards as we collect data on everyone regardless of there teaching status, or service. Neuro and other services use beds on the ward all the time and they are included. You had asked Dr Roberts for direction on this matter of whether he wan't data on neuro patients on the non-teaching side and my understanding is the question has not been addressed.GHall 13:04, 19 January 2011 (CST)

Paper Worksheets used

  • optional preference of the data collector to have paper records
  • Notes can be left by double clicking on the note section, at the time of sending files delete the notes. You may need to leave notes that are relevant to that file for example a abnormally high wbc.

Go to: HSC_H4H serial number share plan for HOB patients only

Daily ward Admit/transfer/discharge ward Binder

  • The standard Admission / Transfer / Discharge ward Log Binder that is used and found at the main desk.Some wards write in the details other use a paper label stamped with the addressograph
  • The ward also has a scribbler that usually has the names of patients admitted,discharged,transferred and moved.
  • The data collector reviews the Admission Binder on each ward, assigns a serial number and enters the minimal data base for all new admissions.
  • The admission and discharge "times" are entered as per the Admission binder. Times are corrected once the chart is reviewed.

Information relevant to patients admitted to D4

  • D4 is a teaching medical ward which in close proximity to the renal clinic,and specializes in renal patients.It is the designated ward for the renal transplant patients which includes post operative care

Data Collection for Renal Transplant Patient

  • Patient Type (Registry): Surgical
  • Admit diagnosis:Pre-Optimization-893
  • Complication is only one of:
    • Renal Transplant-living donor-805-04
    • Renal Transplant-Cadaver donor-805-05
  • See Renal Coding Considerations
  • usually patients are admitted from their home.If the recipient patient is not living in Winnipeg and is receiving a cadaveric donor kidney they may be instructed to go to their nearest hospital and arrangements will be made to transport them to HSC.
  • The living donor recipients are scheduled by the renal clinic.The clinic will forward this information the week prior to surgery with the names of both the donor and recipient.Living renal transplants are performed on Thursdays and the patients are admitted Wednesday afternoon.
  • Usually these patients have a co-morbidity of chronic renal failure. These patients are treated with hemodialysis or peritoneal dialysis.Occasionally the patient may receive a transplant before needing dialysis,in that case code chronic renal insufficiency mild or moderate depending on their creatinine.
  • Once the patient has received a successful renal transplant and is discharged from the hospital,the next time they are admitted to hospital chronic renal failure will not be captured as a co-morbidity unless the transplanted kidney fails to function and dialysis is started again.
  • Immune compromised renal transplants very occasionally become CMV+ or EBV+. This occurs when the donor is positive for CMV or EBV and the recipient was negative.The blood test is done by the Cadham Lab.The nephologist will document his in the history or progress notes.The transplant recipient will be started on anti-viral medications approximately one week post-op and will continue these medications for six months and in conjunction their immune suppression drug dosage will be titrated lower.
  • N.B Chronic renal failure patients who receive a transplant that is not successful,cannot have acute renal failure as an acquired diagnosis for our medical collection data program.This might be captured as delayed graft function/renal transplant problems other,or sometimes it is related to acute tubular necrosis and can be proven by renal biopsy. Other problems will be documented by the Nephrologists.Some problems are:

Renal Donor Patient

  • Patient type is surgical
  • They are admitted from recovery room.
  • Initial vital signs are taken from the last recorded in recovery.
  • The admission diagnosis will be 80100 - NEPHRECTOMY 80101 - Kidney Donor
  • The Nephrologists state the donors always have a renal biopsy on the donor kidney, but the surgeon may not document this.
  • ADL's are to reflect the patient's level of independence prior to surgery (home).

Information relevant to patients admitted to B3

  • B3 is both a medicine, and surgical unit.There is no B medicine service. The unit is split into two, ten beds to medicine, the rest to day surgery.

There is a white board opposite the main desk and the inpatients (which are medicine) are written in Black. Cathy is the unit clerk and is more then willing to help any new comer out. Space is very limited on B3 log book is kept at the desk--PStein 12:07, 6 December 2010 (CST)

Medical Records

  • Audit Box 59
  • requests are written then may be faxed to Lorna at 75002,it could take a few days to receive or a print out of the MR list can be hand delivered to Lorna and placed in her incoming mailbox.
  • charts requested before 1400 hrs will be pulled by MR staff overnight and be available next day is the general rule of thumb.

Technical Support

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