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:
Location of information
Until STB Electronic Patient Record access/orientation completed, use the Wards' daily admit/transfer/discharge binder for the Ward date/time of event. If no time marked in, refer to the nurses notes in the charts Integrated Progress Notes.
- Template:Discussion is this still valid? Ttenbergen 18:13, 2013 August 8 (CDT)Ttenbergen 16:07, 2013 December 16 (CST)
vacation coverage
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 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 has recently gone 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), and hence apache for these patients still need to be obtained from the paper 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)
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 medicine apache score. These elements are usually found in the ER nurses notes, or the MICU flowsheet (for those patients transferred to medicine from MICU). Both of these forms are still paper.
Lab results
Hard copies of the Lab results will be on the chart within 24 hours of admission, if not much sooner.
- why or how is this relevant? is it different from elsewhere? How does this relate to the STB Electronic Patient Record? Ttenbergen 18:33, 2012 October 31 (EDT) Ttenbergen 16:12, 2013 December 16 (CST)Template:Discussion