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

Location of information

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

Process for identifying EMIPs

See EMIP for definitions and general collection information.

We obtain our lists of EMIP patients for medicine from the EMIP Report. We run this report at least once a week.

For EMIP entry there is a separate paper log sheet that has its' own sequential numbers.

• For EMIP pts, you cannot put discharge to an ER, so if that is where they went, put the place they went after ER (usually a ward). Do not put a transfer ready date and time unless the pt is going home. Just put "no transfer ready" in the tmp.

Definition of EMIP:

• 1. Pt has an order that medicine has accepted the patient while still in ER.
• 2. The patient either is discharged from ER to home or any other out of hospital location

OR.. the patient is transferred within the hospital directly to a different service because Medicine decides that they will not take the pt but the patient needs different care. Examples: Palliative care take over the care; ICMS takes over the care; Surgery takes over the care; Gynecology takes over care; etc.

• These patients are only under medicine while they reside in ER. Once they leave ER they are either going out of hospital or going to a different service within the hospital.

Medicine Overflow Patients

• Medicine service patients that spend all or part of their time on an off-service ward.

Overflow patients

Process for identifying Overflow Patients

1. Go to Citrix Apps on Desktop
2. Click on EPR Reports
3. Log in with username and password (same as your initial log into your computer)
4. Click on “Patient List Reports”
5. Click on “Transfer Register”
6. Fill in Facility (hospital you are checking)
7. Put in a time frame that you wish to search. Do not use the current date as you want it to reflect full days, not a partial day.
8. Fill in unit as "emergency" of the correct facility
9. Under “unit filters on”, select “from or to”. All other fields remain unchanged.
10. Click on "View Report" button.
11. Scroll though the list to look for only internal medicine patients that went to off-service wards. (Do not count patients that go to ICMS).

STB Med Office tracking of ovrflows

1. Write down a list of these patients with their chart numbers on a paper.
2. Place this list on the bulletin board in the medicine office so that both medicine data collectors are aware that there are medicine service patients on off-service wards in the hospital.

Entering Overflow patients

• If these patients ultimately get transferred to one of the medicine wards (E5, E6 or B5), then the data collector that does that ward will enter those patients on their laptop, reflecting their entire stay from the admission from ER. In the dispo tab the Off ward field must be ticked off as they were off ward for part of their stay.
• If these patients get discharged from the off service ward to home or out of hospital location, then these are considered overflows that must be entered on the E5 laptop.
• This patient list is posted on the bulletin board of the medicine office. If they are admitted to one of the medicine wards, then that data collector will cross that person off the list. Once a week check if the pt is still in the hospital, if they have left and were never admitted to one of the medicine wards, then the E5 data collector will enter them on her laptop. --LKolesar 06:48, 2017 February 1 (CST)

Who collects Overflow and EMIP Patients

• EMIP's and Overflows at STB are collected on the E5 laptop only.

Patients who are on off service wards part of their stay only

• When a pt comes to E5, E6 or B5 from an off-service ward (this includes 6AS), the data collector must go to the original presentation of the pt to see if this pt was accepted to medicine on the off-service ward prior to their arrival on their own ward. If you see that the pt was looked after by internal medicine prior to their arrival from the other ward, make sure you start your profile on the original date that medicine accepted them (usually in ER).
• On occasion medicine patients are transferred to off service wards, but are still admitted under the internal medicine service. ie. patient transferred from E6 to 7AS (surgical ward) but still admitted under internal medicine. The attending may be different than the admitting service but it is still an internal medicine attending. Please continue to follow these patients (new profile is not required) until they are discharged or transferred to an off service ward under family medicine or any other service other than internal med. Please note the location in the RECORD box to indicate where the pt is currently located.

How to determine when a patient is no longer under an internal medicine service

In the EPR the patient list will show the "provider" which should identify which service the attending physicians is from. However, because this is not always consistently kept up to date when services change, the following checks can help to determine if a patient remains under internal medicine or switches to another service.

1. In EPR,Check the orders under transfers/care directives, to see if there has been an order to switch from internal medicine to another service. Use the time transfered to the other ward as the discharge time or use the time in the order when the other service took over care if the pt remains on the off-service ward.

2. In EPR, go to the patient info tab, select care providers from the left hand column, a list should come up with providers and their discipline with a date. If you see that the most recent attending is no longer an internal medicine physician then there has likely been a change of service. You may be able to confirm this by checking under the documents tab, sort by discipline, and then check the medicine notes that correspond to the date found in the care providers list. The progress notes from different services will be identified as such in the notes section. If you determine that they are in fact now under a new service (with no corresponding order), use the date and time of the attending switch in the care provider list as your discharge date and time.

vacation coverage

Vacation relief

• for Elaine, coverage is for E6 and B5
• for Debbie, coverage is for E5

• 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.

1. do 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 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.DPageNewton 14:40, 2013 February 20 (EST)

items not yet on electronic chart

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.--LKolesar 13:28, 2017 February 6 (CST)

APACHE score

• the medicine apache score. The patients admitted to the wards from MICU, are the only patients that you would need to look on the paper chart. Patients admitted/transferred from either ER or other wards have the apache elements online in the epr. Look in the MICU flow sheet for the apache elements for those patients coming from MICU.
• Techinically the elements for medicine are only HR, SBP, RR, GCS and WBC which is part of the MOST score (not really an apache score). We are using the term "apache" because on the medicine laptops the tab is labelled as "apache".

Lab results

Lab results are now entirely online in the epr.

Office and staff

see Category:St Boniface Hospital Office (Medicine)