STB Medicine Collection Guide: Difference between revisions

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This article contains information specific to STB Medicine, see the [[Medicine Curriculum]] for general information, and [[STB Collection Guide]] for St Boniface specific information.
This article contains information specific to STB Medicine.
*See '''[[STB General Collection Guide]]''' for general STB information such as: links to EPR, Mail room, medical records. Information also in regards to obtaining hand sanitizer, wipes, printer paper for collection offices.
*See '''[[Medicine Curriculum]]''' for general 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. ''
''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. ''
* The Respiratory service admits patients to B5 under the SBGH Internal Med / Respiratory service. The number of beds that are occupied by these patients can fluctuate from day to day and as such so will the census for medicine patients that are admitted to B5. We do NOT collect data on the patients admitted under the respiratory service.
*When a patient is discharged to B5 under the respiratory service the [[Dispo field]] should be STB_Ward, similarly if you admit a patient from B5 that was under the respiratory service the [[Admit from]] should be STB_ward
*We do collect nephrology patients that are admitted to B5.


See also:  
See also:  
* [[STB B5 Collection Guide]]
* [[STB B5]]
* [[STB E6]]
* [[STB_E6_B]]
* [[STB E5]]
* [[STB E5]]
* [[STB EMIP]]
* [[STB EMIP]]
== 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".
== STB Swing Beds ==
*STB Swing Bed entries are "bed" records within a "unit" in EPR/Cognos. They are not beds or locations but conceptual service location and time entries used for patient moves. This data causes a patient record to show up in Cognos/CUS as having arrived on a unit even when the pt has not actually arrived, and it isn't visible in our listings whether the record is for a swing or real bed.
*Since any CUS entry at STB may be either a swing bed or a real bed, service locations and times need review.
For Medicine, the swing bed entries will often be obvious as the unit stays will be a matter of minutes
If a CUS entry is for a swing bed, manually exclude using the "exclude" button


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.)
== Location of information ==
 
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. [[User:DPageNewton|DPageNewton]] 12:19, 2017 June 6 (CDT)
* [[Cognos2]] is used for collection of Admit/Transfer/Discharge (A/D/T) dates/times
**See [[Using Cognos2 to keep track of patients]] for further information


== [[Off ward field]] ==
* The [[STB Electronic Patient Record]] is used to review documentation as needed and to complete collection for patient discharges
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.


== vacation coverage ==
Vacation relief
* for Elaine, coverage is for E6 and B5
* for Debbie, coverage is for E5


{{discussion}}
See [[Visit Admit DtTm field]] for further information
* Is any of this different from [[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.
#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.
#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 have to be pulled from medical records by the person returning from vacation. This would help tremendously in catching up from time off for the returning collector.[[User:DPageNewton|DPageNewton]] 14:40, 2013 February 20 (EST)
== Boarding Loc ==
[[Category:Vacation]]
see [[STB_Medicine_workload_splitting#Boarding_Locs]]


== items not yet on electronic chart ==
== STB Medicine workload splitting ==
===[[Overstay Predictor Project Collection Instructions|Overstay Project]] ===
SBGH has now gone to paperless charting or [[STB Electronic Patient Record]]. This means that we can now review almost the entire chart on the computer. The exceptions to this are:
*the DPST Form. The information found on this form is one part of the information we need for the overstay predictor project (opp).
**The DPST is not being completed on E5 for the last few months.  Need to see if the overstay program will be continued or not.--[[User:LKolesar|LKolesar]] 13:28, 2017 February 6 (CST)


=== APACHE tab ===
=== STB Medical Records requests ===
To collect the elements of the [[MOST]] score, on the Apache tab:
* Not needed for STB Medicine Program collection
* for patient who come from MICU , look on the the MICU flow sheet
* for all other patient use EPR vital signs


== Lab results ==  
== APACHE tab ==
Lab results are now entirely online in the epr.
Use EPR vital signs to collect the Medicine items for Apache


== Office and staff ==
== Office and staff ==
see [[:Category:St Boniface Hospital Office (Medicine)]]
see [[:Category:St Boniface Hospital Office (Medicine)]]


== Related articles ==
{{Related Articles}}


[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:St Boniface Hospital Office (Medicine)]]

Latest revision as of 09:34, 2024 March 13

This article contains information specific to STB Medicine.

  • See STB General Collection Guide for general STB information such as: links to EPR, Mail room, medical records. Information also in regards to obtaining hand sanitizer, wipes, printer paper for collection offices.
  • See Medicine Curriculum for general 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.

  • The Respiratory service admits patients to B5 under the SBGH Internal Med / Respiratory service. The number of beds that are occupied by these patients can fluctuate from day to day and as such so will the census for medicine patients that are admitted to B5. We do NOT collect data on the patients admitted under the respiratory service.
  • When a patient is discharged to B5 under the respiratory service the Dispo field should be STB_Ward, similarly if you admit a patient from B5 that was under the respiratory service the Admit from should be STB_ward
  • We do collect nephrology patients that are admitted to B5.


See also:

STB Swing Beds

  • STB Swing Bed entries are "bed" records within a "unit" in EPR/Cognos. They are not beds or locations but conceptual service location and time entries used for patient moves. This data causes a patient record to show up in Cognos/CUS as having arrived on a unit even when the pt has not actually arrived, and it isn't visible in our listings whether the record is for a swing or real bed.
  • Since any CUS entry at STB may be either a swing bed or a real bed, service locations and times need review.

For Medicine, the swing bed entries will often be obvious as the unit stays will be a matter of minutes If a CUS entry is for a swing bed, manually exclude using the "exclude" button

Location of information


See Visit Admit DtTm field for further information

Boarding Loc

see STB_Medicine_workload_splitting#Boarding_Locs

STB Medicine workload splitting

STB Medical Records requests

  • Not needed for STB Medicine Program collection

APACHE tab

Use EPR vital signs to collect the Medicine items for Apache

Office and staff

see Category:St Boniface Hospital Office (Medicine)

Related articles

Related articles:
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