STB ACCU Collection Guide
This article contains collection information specific to the CCU (Cardiac Care Unit) at St Boniface.
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
Admission and discharges unit Log book is found at the Unit Ward Clerk Desk.
Ward Contacts
ACCU 235-3843
Fax 235-3848
Rosanne (PTM) 235-2981
Chris (Educator) 235-3997
Helen (Ward Clerk) 235-3843
Collector "base"
Admissions, Discharges and Transfers can be found the EPR. Check these against the Log Book kept at the Ward Clerks desk. TISS sheets post discharge, are kept in a binder at the Ward Clerk's Desk. Rogue TISS sheets can sometimes be captured in the charts in the new patient location, in Medical Records, or have to be re-done if lost in transit. Review the TISS sheets and any paper chart components in ACCU at the bedside. This information is readily accessible early morning prior to 0700. Work surfaces in the new ACCU are very limited, so borrow a bedside table from an empty room and use this as a work surface. When finished, clean the bedside table and replace to original position. Computers are available in the Common Work Area accross from the Main Desk. All other chart information is on EPR which can be reviewed in our office on the computer.
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.
Patient exclusions
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 ACCU for post procedure care after an angio they send the patients to ACCU for recovery only when the pre and post angio area is closed, usually in the late evenings and nights.--LKolesar 12:12, 2014 July 25 (CDT)
Elective Cardioversion
When patients come to ACCU for an elective cardioversion only, they are not entered into the database. This is also a bed borrow.
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. --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 related to the Angiogram outcome (ie stenting) then the Myocardial infarction (with location subcode) and then other related admit dx (CHF, ETC.) 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 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.