Minimal Data Set

Data on all patients gets sent to the Regional Server each week that files are sent; see Sending Patients for details.

Data that must be collected for all patients as soon as possible

• If 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:
  • serial number
  • hospital
  • unit / location
  • first name
  • last name
  • hospital chart number
  • unit admit date (time not necessary)
• As soon as possible the following need to be entered, but their absence may not stop the program from sending:
  • admit time
  • discharge date and time
    • Importance of discharge DATE
    • How discharge date is used in PDA_Pending.mdb
  • data for those TmpV2 entries where instructions say that all data is sent at every send

Template: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 practise is to use the date and time that is entered on the "INPATIENT SUMMERY 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 transfering patients from acute to non-acute medicine.)

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:

• 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

Removal of DOB and PHIN from the list

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.