STB ACCU Collection Guide: Difference between revisions

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This article contains collection information specific to the CCU (Cardiac Care Unit) at St Boniface.  
This article contains collection information specific to the Acute Cardiac Care Unit at St Boniface, [[STB_ACCU]].
 
See also [[ACCU borrow]], [[STB Cardiac Care patients]].


''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles. ''
''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles. ''


See the following for more general information:
See the following for more general information:
* [[STB Collection Guide]]
* [[STB General Collection Guide]]
* [[STB Critical Care Collection Guide]]
* [[STB Critical Care Collection Guide]]


== Unit admission log book ==
== Unit admission log book ==
Admission and discharges unit Log book is found in CCU where the bedside chart slots are.
The log book is no longer used to track admissions, see [[Using Cognos2 to keep track of patients]].
 
Admission and discharges unit Log book is found at the Unit Ward Clerk Des
 
== Ward Location ==
ACCU is located in SBGH on 5AW. The unit is referred to in our boarding locations as CCUO, but remains ACCU in the pre-admit location, previous location & dispo fields on the profile home page.


== Ward contacts ==
== Ward Contacts ==
The ward clerk on Days in CCU is Helen, Christine is the Ward clerk on 5ACM
[[STB_ACCU#contacts]]
{{discussion}} Do you ever need to contact them by phone? If so, what's the number. If not, pls delete this point. Ttenbergen 10:09, 2014 July 24 (CDT)


== Collector "base" ==
== Collector "base" ==
Just review the TISS sheets and any paper chart components in CCU or in the charting room on 5A.  There is very little space to work in CCU right now, you can ask the ward clerk where you can sit to review the charts. A new CCU is under construction and hopefully this will not be a problem then.All other chart information is on EPR which can be reviewed in our office on the computer.
Admissions, Discharges and Transfers can be found the EPR.


== Location of patient chart components ==
== Location of patient chart components ==
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== Charting Note ==   
== Charting Note ==   
The CCU patient chart has a flow sheet for the nurses to fill out their vital signs and patient assessments.  If the patient has had an acute MI, a care map type of flow sheet is used.  This has four steps as the patient progresses in their recovery.  A second option for nurses’ charting is a CCU flow sheet for all other types of patients other than acute MI.  (examples:  arrythmias, pre op optimizations, cardiomyopathy, chest pain NYD, etc. ).  Occasionally a COR sheet (like those used on the wards) can be continued in CCU and even the Y2 procedure note page has been continued on a rare occasion for a patient who needs some CCU management post angio. 
The ACCU patient chart now only uses the ICU flow sheet.
 
== Post-Angio patients exclusion ==
We do not collect patients who arrive in CCU for post procedure care post [[angio]] '''only because the pre and post angio area is closed'''.
{{discussion}} What do you mean? If they opened it tomorrow, would that change collection? Will it open again? Ttenbergen 10:10, 2014 July 24 (CDT)


== Paper notation for primary angios ==
== Other STB ICU collection guides ==  
On the paper log sheet we put a small heart figure to indicate all primary angios in the admit-from space but you also need to put where the patient was just prior, which is also written in this space.
{{discussion}}
Is this the paper log sheet in your own binders? Or is there another? Ttenbergen 10:09, 2014 July 24 (CDT)
 
== Diagnostic Coding vs Admit-From==
Primary angiograms are those that go first to the angio room and then to CCU afterwards.  In this case the first admit diagnosis should be angiogram, then angioplasty, then stent, then the MI with location subcode and then other items like CHF or TNK if applicable. 
The exception to this rule is when the patient has a cardiac arrest before arriving in CCU or has cardiogenic shock.  These will then be coded first and then the primary angio sequence.  If you are past the quota for number of admit diagnosis codes, you can use only angioplasty if necessary (take out angiogram and stent if needed).
 
If the patient comes from an ICU (different hospital) do not use the MI as the first diagnosis.  Other options could be post infarct angina, unstable angina, chf, cardiogenic shock, etc.  The second diagnosis could be the MI.
 
=== This needs to go elsewhere ===
{{discussion}}
This is probably not unit specific information so it should be moved to the relevant articles so all collectors will connect it the same, and so that when we look up information about the topic we don't miss anything because it's buried in the site specific info. Could someone please split this out to the relevant articles? I get the feeling one of the collectors would know better what needs to go where, but when it's done this heading/section should be gone.
 
* Most of the above is a special case of the instructions in [[Admit Diagnosis]]. I think that doesn't even need to be transferred.
* Some more of it is specific to [[Angioplasty]] or [[Angiogram]]
 
== Other STB ICU collection guide info STB CCU Collection Guide ==  
*[[STB CICU Collection Guide]]
*[[STB CICU Collection Guide]]
*[[STB MICU Collection Guide]]  
*[[STB MICU Collection Guide]]
 
 


== Related articles ==
{{Related Articles}}


[[Category:St Boniface Hospital Office (Critical Care)]]
[[Category:St Boniface Hospital Office (Critical Care)]]
[[Category:Site Specific Collection Guide]]
[[Category:Site Specific Collection Guide]]

Latest revision as of 11:49, 2023 August 29

This article contains collection information specific to the Acute Cardiac Care Unit at St Boniface, STB_ACCU.

See also ACCU borrow, STB Cardiac Care patients.

Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles.

See the following for more general information:

Unit admission log book

The log book is no longer used to track admissions, see Using Cognos2 to keep track of patients.

Admission and discharges unit Log book is found at the Unit Ward Clerk Des

Ward Location

ACCU is located in SBGH on 5AW. The unit is referred to in our boarding locations as CCUO, but remains ACCU in the pre-admit location, previous location & dispo fields on the profile home page.

Ward Contacts

STB_ACCU#contacts

Collector "base"

Admissions, Discharges and Transfers can be found the EPR.

Location of patient chart components

Most information is on EPR. There still are heart cath reports stored on paper but usually heart caths also are reported on EPR. Echo reports on paper chart.

Charting Note

The ACCU patient chart now only uses the ICU flow sheet.

Other STB ICU collection guides

Related articles

Related articles:
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