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]].


== Ward contacts ==
Admission and discharges unit Log book is found at the Unit Ward Clerk Des
The ward clerk on Days in CCU is Helen, Christine is the Ward clerk on 5ACM
 
== 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" ==
== 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.
*When the new CCU opens (hopefully end of June 2016), it is likely that the patient charting structure will change. This will be updated once we know what the structure will be.  We have heard that they will only use the ICU flow sheets and may no longer use the Acute MI care map structure but we will wait and see. --[[User:LKolesar|LKolesar]] 08:51, 2016 June 8 (CDT)


== Patient exclusions ==
== Other STB ICU collection guides ==  
=== Post-Angio ===
We do not enter patients into the database when the cath lab is recovering patients there (borrowing a bed).These pts are only in CCU for post procedure care after an [[angio]] '''they send the patients to CCU for recovery only when the pre and post angio area is closed, usually in the late evenings and nights'''.--[[User:LKolesar|LKolesar]] 12:12, 2014 July 25 (CDT)
=== Elective Cardioversion ===
When patients come to CCU for an elective cardioversion only, they are not entered into the database.  This is also a bed borrow according to Marla Penner.  --[[User:LKolesar|LKolesar]] 17:54, 2015 August 18 (CDT)
 
== Paper notation for primary angios ==
On the paper log sheet in the data collectors' binder, we put a small heart figure in the admit-from space to indicate all patients who come directly from the cath lab.  You must also put where the patient was prior to the angio in this space.  This includes, but is not limited to, primary angios.
*Primary angio means the patient came directly to the cath lab via EMS or they are first sent to angio before other interventions are done in ER.  --[[User:LKolesar|LKolesar]] 12:20, 2014 July 25 (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 [[Coronary stent insertion]], then the [[Myocardial infarction]] with location subcode and then other items like [[CHF]] or [[50504 - CVA Post Anticoagulation TX (STK, TPA, TNK, HEP)|TNK]] if applicable. 
The exception to this rule is when the patient has a cardiac [[:Category:Arrest|arrest]] before arriving in CCU or has [[Cardiogenic Shock]]. These will then be coded first and then the primary angio sequence.
 
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.
 
== 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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