Factors Identified Effecting Quality of Data

This list has been generated after the presentation of the results of the Peer audit at the Team Meeting September 29 2010.

Please feel free to add other thoughts and ideas Template:Discussion

One example identified at a meeting today by CMarks was if there is no MOST, because a patient was in palliative care, and only vital signs available is from 1 week prior to acceptance to medicine service then what do you put in as a BP, HR, WBC? The guidelines state if there are no values assume normal. But what are the normal values that should be recorded?
- Solution: Tina suggested putting not available and when data sent to Server, values will be output as a preset standard normals.
Another example ID'd by LBilesky was for APACHE - the exact physiological item is not recorded because APACHE score is based on selecting a value within a RANGE for points. If the points are the same why fuss about which value to select? There were never any guidelines instructing a collector which value to choose within a range.
- Solution: Update guidelines for APACHE II collection rules.
PStein - ID'd that she sometimes find 2 or more sources of DATE and TIME first accepted to the Medicine Service. She uses the first date and time she finds on the chart?
- Solution: Update guidelines so that FIRST date and time found on a chart or EPR at STB is recorded.
FLindell - if actual med ward arrival time is obtained the data collector from the ward log book, then a auditor of a chart would not have assess to the log book, hence the ward arrival date and time is not easily reproduced. --TOstryzniuk 17:24, 30 September 2010 (CDT)
- Solutions: ?

Discussion

Some collectors take the time of acceptance by Medicine from the doctors orders in the chart and compare it to the Admission/Separation sheet admit time,then compare to take the earliest time.For arrival time on the ward they look at the nurses notes to see if it is clearly documented and in that case they will take that time. If the arrival time is not clearly charted they look at the log book for a time.They also look at notes of the sending location to see if there is a departure time and compare it to the arrival time to see if it makes sense.