STB Medicine Collection Guide: Difference between revisions
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Revision as of 21:45, 2020 March 29
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:
Location of information
We use EPR for all Admit/Transfer/Discharge times.
Accept DtTm is found under the orders tab, Transfers/Care Directives. You will see an "admit to inpatient order".
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Arrive DtTm is 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.)
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See Visit Admit DtTm field for how to collect this field.
Transfers between different units can be found in the same Location History window as Arrive Date & Time and Visit Admit Date & Time.
Dispo_DtTm 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.
Boarding Loc
Full-time Boarding Loc ward patients are captured on the E5 laptop only.
Are they identified with Identifying patients in boarding locations or how? |
Workload distribution
See STB Medicine Workload splitting
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.
- ADL's 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.
- 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 STB_MICU. STB_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.
items not yet on electronic chart
APACHE tab
To collect the Medicine items 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
Office and staff
see Category:St Boniface Hospital Office (Medicine)