Minimal Data Set
The Minimal Data Set is the least amount of data that needs to be collected for a new patient when they are first added to the database. This data is sent every shift worked for all patients, not just those you are sending. This data needs to be entered for all newly admitted patients during every data collection shift. With the exception of special requests from the main office, it is more important to collect this data than to complete collection for existing patients, especially for incomplete files.
If you try to send with any of the Minimal Data Set Elements incomplete for any patient (even ones you are not sending), the CCMDB.accdb will give an "incomplete minimal data set" error and list the patient, and you will not be able to send any patients.
Minimal Data Set Elements-Primary
For all new patients at every shift enter the following from EPR:
- Serial number
- First Name
- Last Name
- hospital Chart number
- hospital Visit Admit DtTm
- Accept DtTm
- Date of Birth (DOB)
- first Boarding Loc - start_dt and start_tm
- first Service tmp entry - start_dt and start_tm
As it becomes available data elements
The following should be entered as they become available through Cognos:
- Screening and entering dispo date each shift is important for knowing:
- which are the oldest discharge dates that must be prioritized for data collection in Medical Records.
If we want to prioritize like that it needs to be discussed in whatever page talks about data collection process and priorities - not here. That could link to here.
- how many profiles with discharge dates are still outstanding
- Occupancy reporting. This info is requested often. The statistician includes reporting the number of outstanding incomplete files.
Other data that is required as early as possible
Operationally what does "as soon as possible" mean? What collector process would capture this prior to the final chart review. If we want a requirement it needs to be actionable.
Data for patients that have not yet been sent is still used for reporting, so please add it as soon as it becomes available. During every shift, please review and try to ensure that the following data is as complete as possible, even for incomplete patients:
- Previous Location
- Pre-admit Inpatient Institution
- COVID-19 (SARS-COV-2) positive in ICD10 if known
- Invasive Mechanical Ventilation (TISS Item) for one date in CCI_picklist for COVID positive only
- ETT Present (TISS Item) or Trach Tube Present (TISS Item) for one date in CCI_picklist for COVID positive only
The absence of these items will not stop the CCMDB from sending files. These items are allowed to be empty since they may not be available initially, but they should be filled in as soon as available. Previous Location, Dispo Date is most important to enter into data ASAP.
Reason why data is required for patients that are not complete yet
Data in the minimal data set is sent for all patients as soon as available, even before the patient's RecordStatus field is set to "complete". This allows us to include longer-stay patients who have not yet been discharged in our statistics and reporting.
Data from patients who are not yet complete is used for the following:
- to generate occupancy statistics
- to be able to finalize temporary studies before long-stay patients are eventually discharged
- to monitor the number of outstanding patients
- to link the movements of patients from one ward/service to another ward/service
- to calculate the median and mean LOS of patients
Data Integrity Checks (automatic list)
|Query check minimal data set incomplete||CCMDB.accdb||implemented|