Lost/missing chart: Difference between revisions

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*A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (180 days) after the patient has been discharged from the hospital or died in hospital.
*A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (180 days) after the patient has been discharged from the hospital or died in hospital.
*At that point the laptop record will be given the status of '''Discontinued'''.
*At that point the laptop record will be given the status of '''Discontinued'''.
*The mechanism for recognizing this situation, and changing the record status will be ad hoc, and work through Pagasa.
*The mechanism for recognizing this situation, and changing the record status will be ad hoc, will work through Pagasa.


== Instructions for finishing off the profile ==
== Instructions for finishing off the profile ==

Revision as of 12:19, 2021 June 15

Working on std instructions on what to do about lost charts. More to come.

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Additional info

  • A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (180 days) after the patient has been discharged from the hospital or died in hospital.
  • At that point the laptop record will be given the status of Discontinued.
  • The mechanism for recognizing this situation, and changing the record status will be ad hoc, will work through Pagasa.

Instructions for finishing off the profile

An profile for a missing chart might trigger CCMDB.accdb Data Integrity Checks, so it can't be sent the normal way and the following process applies instead.

Instructions for Collectors

  • Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible
    • This includes any diagnostic imaging and procedure counts and results, lab results, etc
  • Where you can not get past a cross check because data is not available, explain that in the Notes field
  • what should be the instruction for APACHE - the usual "enter normal if not available" or should they enter extremes or 0s, or leave blank? What will not mess with Julie's processes?
    • I would rather have a missing APACHE Score when any of the APACHE elements are missing due to Lost or missing chart. Entry of zero for numeric or blank for character on any of the elements results to blank APACHE Score (but this refutes the guideline for APACHE Physiologic Not available). Normal values result to Zero APACHE Score (when age pts is zero).
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the following doesn't apply yet, waiting to confirm as of 2021-04-07   
  • When you have entered all available information, and when the #Deferral period has passed, contact Pagasa and tell her the profile is a missing/lost chart
  • Once Pagasa has confirmed that this is understood, delete the chart using the ♻️ button

Instructions for Data Processor

  • Do we want a different RecordStatus for these? If not, should they be considered complete or incomplete?
    • I suggest we enter a new one say, LostChart, in the RecordStatus which implies incomplete and some data are missing. --JMojica 13:34, 2021 April 7 (CDT)
      • Would there be any problems with reporting queries including or excluding these in unintended ways? Could happen if any use a "not incomplete" or similar. I am pretty sure if we change this some CFE cross checks will show false positives for these, but those would be easily tweaked as we encounter them. Would there be false negatives, though? Ttenbergen 14:15, 2021 April 7 (CDT)
        • do you have a query about missing entry in any fields? I can't think of any query with false negative. --JMojica 17:13, 2021 April 7 (CDT)
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Incomplete/lost profiles

Julie says Pagasa keeps a list of records for which this applies. Can we keep it here instead? If there are good reasons not to, can we link from here?

  • If we change the RecordStatus to LostChart for these there will be no need for lists, just a one-time update needed by Pagasa; I think that would be the best way to do this.
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click expand to see list   
  • HSC_D5-36
  • HSC_D5-39
  • HSC_D4-3
  • HSC_SICb-1409
  • HSC_SICa-1887
  • STB_MICU-15213

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