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Minimal Data Set, parts A & B below, must be entered '''DAILY''' onto the [[Laptop Setup | laptop]] for '''ALL NEW admissions''' as soon as possible each day you are in to collect data.
The '''Minimal Data Set''' is the least amount of data that needs to be collected for a new patient when they are first [[adding a patient | added]] to the database. This data is [[Sending Patients | 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 [[:Category:Main Office | 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.


If '''part A''' of the '''minimal data set''' is not complete for '''any''' patient, the [[CCMDB.mdb]] 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]]
* [[Service/Location]]
* [[First Name]]
* [[Last Name]]
* [[PHIN field|PHIN]]
* hospital [[Chart number]]
* hospital [[Visit Admit DtTm field | Visit Admit DtTm]]
* [[Date of Birth| Date of Birth (DOB)]]
* first [[Boarding Loc]] - start_dt and start_tm
* first [[Service tmp entry]] - start_dt and start_tm


==Minimal Data Set Elements ==
*A. '''Daily, ALL NEW patients''':
** serial number
** hospital
** unit / location
** first name
** last name
** hospital chart number
** unit admit date (time not necessary)


* [[Postal Code]] should be included if available from [[Cognos]] but is known to sometimes change during the admission; we don't expect collectors to quality check this on incomplete records
*B. Daily also, when you are in collecting data , the following also need to be entered onto the [[Laptop Setup | laptop]] as soon as it is available: 
* [[Previous Location]] should be entered if easily available from Cognos data, but is not required if it requires further data review
** '''admit time'''
** '''discharge date and time ''' 


*** [[Admit, Transfer and Discharge date and time#Priority_collection_before_sending | Importance of discharge DATE]]
NOTE: The absence of these two items in Part B, will not stop the [[CCMDB.mdb|CCMDB]] from sending files from your [[Laptop Setup | laptop]] to the [[Regional Server]].


*** How discharge date is used in [[PDA_Pending.mdb | Pending.mdb]]
== Reason why data is required for patients with [[RecordStatus]] incomplete ==
** data for those '''TmpV2''' entries where instructions say that all data is sent at every send
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 counts of longer-stay patients who have not yet been discharged in our statistics and reporting.


Data on '''all''' patients gets sent to the Regional Server each week that files are sent; see [[Sending Patients]] for details.
==Instruction STB Med Minimal Data Set - Primary Source for the Admit date/time to Medicine Service:==
*a. For Acute Care Medicine patients at STB, use the Doctors orders on the EPR as date/time accepted to Medicine Service.--[[User:TOstryzniuk|TOstryzniuk]] 17:26, 21 September 2010 (CDT)
*b. for Non Acute Care - C service medicine patients at STB, use_______? for date/time accepted to medicine service.
==Discussion==
{{Discussion}}
Question for SBGH data collectors (or anyone else who would like to offer an opinion):
*Where is the most reliable place in the chart to get the admit date and time (i.e. the time that the patient is admitted to your medical service)?
*It has been my experience here at SBGH that there is not a consistently reliable place where we can get that information, since there is no one specific "spot" that this information is documented.
*Our current practice is to use the date and time that is entered on the "INPATIENT SUMMARY SHEET" since this sheet is on every patient's chart.
*It is my understanding that this time however, is nothing more than the time that the sheet is created by the admitting clerk who enters this information.
*The downfall of using this sheet's date and time, is that you have to have the chart in front of you to get it. If you are trying to get patients entered with minimal data set, you may not always have the chart in front of you. That means you then need to enter a fake date and time and then have to change it later.
*Would a more appropriate date and time be the one that is entered on the EPR, when the order is written to accept that patient to a particular service? (This too, has flaws I know, because the m.d.'s can sometimes be notoriously lacking, when it comes to writing an order to transfer, especially when transferring patients from acute to non-acute medicine.)--[[User:DPageNewton | DPageNewton]] September 16, 2010.
**Good point about where, at your site, each collector should get the most reliable information  for admit date/time to medicine service physician”. The practice should be consistent at your site.
Two things important:
#which is the most reliable source at your site: A. the "INPATIENT SUMMARY SHEET"or B. the Dr.’s order on EPR?
#Standard collection practice: To be consistent, Collectors at a site must obtain the information from the same source.
*I understand that there will always be variability of admit data and time between Inpatient Summary Sheet and the Dr's on the EPR (Electronic Patient Record).  It has been explained to me that sometime the Inpatient Summary Sheet admit date/time is after the Doc order date/time and sometimes it before the Doc orders.
**Debbie, Elaine and Laura and Kym - where do you get your most reliable source for admit date/time at your site for your unit.--[[User:TOstryzniuk|TOstryzniuk]] 19:04, 16 September 2010 (CDT)
***Apparently both Deb and Elaine are taking the Date and Time of admission to Medicine Service from the Med Service physician orders on the EPR. Elaine, is that correct?
****What source does both Elaine and Deb use for date/time admit to non acute C service if Doc's are not writing orders? Please update instruction b above--[[User:TOstryzniuk|TOstryzniuk]] 17:26, 21 September 2010 (CDT)
== Reason why data is required for patients that are not complete yet ==
Data from patients who are not yet complete is used for the following:  
Data from patients who are not yet complete is used for the following:  
* to generate occupancy statistics
* 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 monitor the number of outstanding patients


=== Removal of DOB and PHIN from the list ===
Minimal dataset information can be used for reporting; we will include a caveat that it is preliminary and not yet quality checked. We will not do additional cross checks to validate minimal dataset data on incomplete records. <!-- 2022-08-03 JALT decision -->
We removed PHIN and DOB from this list because it was causing problems entering patients admitted to our ICUs without identification. Chart Number and location should allow us to identify any such patients conclusively anyway.
 
== Cross Checks ==
{{Data Integrity Check List}}
 
== Related articles ==  
{{Related Articles}}




[[Category: Registry Data| *]]
[[Category: Data Collection Guide]]
[[Category: Data Collection Guide]]
[[Category: IT Instructions]]
[[Category: 2016 Time and Place changes]]

Latest revision as of 12:45, 2022 August 24

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:


  • Postal Code should be included if available from Cognos but is known to sometimes change during the admission; we don't expect collectors to quality check this on incomplete records
  • Previous Location should be entered if easily available from Cognos data, but is not required if it requires further data review


Reason why data is required for patients with RecordStatus incomplete

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 counts of 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 monitor the number of outstanding patients

Minimal dataset information can be used for reporting; we will include a caveat that it is preliminary and not yet quality checked. We will not do additional cross checks to validate minimal dataset data on incomplete records.

Cross Checks

Data Integrity Checks (automatic list)

 AppStatus
Query check minimal data set incompleteCCMDB.accdbimplemented

Related articles

Related articles:
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