STB MICU Collection Guide
This article contains collection information specific to the STB_MICU/SICU at St Boniface. STB MICU/SICU also called ICMS, this unit includes medical, surgical and cardiac 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 admission/discharge log book is found at the main desk near where the ward clerk usually sits.
Process of data collection
- Each day the data collector must go to each bedside to obtain data from the nurses' flow sheets which are still in paper format. At this time the tiss sheets which are kept on the bedside chart can be checked to ensure accuracy. Apache vital signs must be obtained from the paper flow sheets. The main paper charts are kept at the individual bedsides as well. It is helpful to view the operative records, angiogram records, endoscopy reports, code blue records, notes sent from other hospitals, etc. at this time.
- As of September 2017, the nurses' operative report is in EPR under documents. The doctor's operative reports have been on EPR for some time already. The anesthesia record is still in the paper chart.--LKolesar 12:25, 2017 September 7 (CDT)
- Once the bedside chart information has been collected and entered on the laptop, there may be ward follow ups. Patients from MICU can be transferred to almost any ward in the hospital (surgical wards are 4AS and 4ASstepdown; 7AS and 7AW, 2B); (acute medical wards are E5, E6); (chronic medicine wards are B5, A6S, E4); (Gyne is A6W); (Cardiology ward is A5S); (Palliative ward is A8W); (Psychiatry is McEwen). (Obstetrics is on the 3rd floor includes L&D, postpartum and LDRP); (CR4 is the cardiac surgery inpatient unit in Asper building).
- Patients that have been discharged will need to have their charts reviewed in Medical Records so this list must be put down and it usually takes 2 days or so to obtain the charts if they are available.
- Once all the paper components have been reviewed and the profiles updated with this information, the data collector can read the EPR information in the Data Office (N4069). EPR contains all physician orders, labs, DI results, MAR, Pt information like address, etc. and all progress notes.
- When reviewing patients that have left the ICU, we check the tiss against the MAR and other EPR information at this time. We also do all the lab counts and Pharmacy counts. We review all of the progress notes up to the time of patient leaving the ICU. After completing all of these patient profiles, the "complete" tab is selected. The completed profiles need to be sent during the designated sending times: Because the Data Processor needs dedicated access to Centralized_data.mdb the time during which collectors are able to send is limited as follows:
- when working from hospital site: Monday to Friday 14:30-18:00
- when working from home: Monday to Friday 07:00-09:00
Cardiology patients
STB Cardiology service patients are collected differently than other patients, see STB Cardiac Care patients for details.
Ward contacts
Collector "base"
- Usually we can utilize the desk that is east of the main desk in the unit. This desk is also utilized by some consultants and pharmacy but it is an excellent space and there are also computers on the desk that we can use for EPR.
- Another option is to use the extra desk space adjacent to Bed 1. You can also use individual desk space throughout the unit if there are any empty bed spots.
- I try to get a bedside table to accommodate my laptop for checking the individual patient flow sheets and tiss sheets and other parts of the paper chart. I can easily move to each individual bedside this way without utilizing the desk areas in the unit. Once I collect the information I need from the bedside paper charts then I read the rest of the charts in the office on EPR and enter this information utilizing Extended desktop external split screens.--LKolesar 18:03, 2015 August 18 (CDT)
Location of patient chart components
The individual charts are kept at each specific bedside along with the tiss sheets. The current green sheets are kept on the rounds cart. The completed tiss and green sheets are kept in a marked binder at the main desk. There is a sheet in the ICMS data collector's binder that has a record of VAP and line sepsis cases. This information is kept and is shared with the charge nurse and Lillian Kolley for ongoing quality control.
- As of January, 2013, all chart information is found in the Electronic Patient Record for MICU except: The nurses flow sheets, OR records, ER records, Echo Reports, Endoscopy reports, heart cath. reports, central line insertion sheets, blood product sheets. (These items are still part of the paper chart). --LKolesar 11:42, 2013 May 6 (EDT)