STB Medicine Collection Guide

This article contains information specific to STB Medicine, see the Medicine Curriculum for general information, and STB Collection Guide for St Boniface specific information.

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 also:

• STB B5 Collection Guide
• STB E6
• STB E5
• STB EMIP
• STB IMCU

Location of information

We use EPR for all Admit/Transfer/Discharge times. ENagy

Accept Date & Time are found under the orders tab, Transfers/Care Directives. You will see an "admit to inpatient order".

Arrive Date & Time are found by clicking on Registration (on top left bar), then Visit Location, then Location History. A new Location History window will pop up that will tell you the date & time that the patient arrived at a particular location. (e.g. patient arrived on E5 medicine from the emergency department.)

Visit Admit Date & Time is found in the same Location History window as Arrive Date & Time. The first date & time listed is the Visit Admit Date & Time.

Transfers between different units can be found in the same Location History window as Arrive Date & Time and Visit Admit Date & Time.

Disposition (or discharge) Date & Time is found under the patient info tab, then clicking Demographics/Visit Data on the left. The discharge information will be on the bottom right of the page. DPageNewton 12:19, 2017 June 6 (CDT)

Off ward field

Full-time off ward patients are captured on the E5 laptop only. Patients whose stay is partly on E6 will be captured on that laptop and have the off ward box checked.

Workload distribution

See STB Medicine Workload splitting - New Nov 2018

vacation coverage

• Vacation and staff shortage collection priorities? Should it be? Ttenbergen 18:35, 2016 November 10 (CST)

For those collectors who are doing vacation relief for the regular collectors who are away, catch up from time off can be expedited for the returning collector if the following things are prioritized.

1. do Overstay Predictor Project (OPP) and color generation. ADL's are a component of the OPP and can be found on the STB Electronic Patient Record. They are in "initial assessment" form under the documents tab. Everything needed for minimal data will be included if the opp is done.
2. medicine apache score. The SBGH ER unit is online with their vital signs and neuro assessment. This means that the vital signs and gcs required for the apache score can now be found under the flow sheets tab. To access neuro check, click on flow sheets, then care and assessment, then neuro. The only exception to this is for patients admitted to the unit from MICU. MICU does not use epr (electronic patient record) for vital signs, and hence apache for these patients still need to be obtained from the paper flow sheet in the chart.

The only things that need to be taken from the paper chart are the dpst info. If the OPP is kept current and up to date then charts would not need to be STB Medical Records requests by the person returning from vacation. This would help tremendously in catching up from time off for the returning collector.DPageNewton 14:40, 2013 February 20 (EST)

items not yet on electronic chart

APACHE tab

To collect the elements of the ALERT Scale, on the Apache tab:

• for patient who come from MICU , look on the the MICU flow sheet
• for all other patient use EPR vital signs

Just to be sure, does this still refer to a non-EPR process? If so please remove this discussion. If not, let's figure out where this fits in. Ttenbergen 13:56, 2017 July 18 (CDT)

• SMW

• Cargo

• Categories

Lab results

Lab results are now entirely online in the epr.

Office and staff

see Category:St Boniface Hospital Office (Medicine)