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
We use EPR for all Admit/Transfer/Discharge times. ENagy
6AS Transitional Care Unit collection guide
Generally speaking patients that have been admitted to any of the active medicine units, E5 (A service), 5B (C service) and E6 (B medicine) are transferred there once they have been deemed medically stable and are waiting for placement or geri rehab, stroke rehab etc.
Medicine would like to track these patients and as such the following situations may arise.
On the very rare occasion patients are admitted directly from the ER or elsewhere to 6AS:
1. If they are admitted under family medicine, we do not admit them, in other words ignore them completely 2. If they are admitted under one of the teaching services, then the collector who collects that data will enter them on their laptop. Ie. If admitted under A Service it will go on the E5 laptop, if B service then it would go on the 6E/5B laptop etc. As for the overstay, the allied health and nursing staff do NOT fill out these forms, so the overstay would be entered as “data missing” and the color would still be generated. If they are a red- there is no binder for allied health staff, so nothing more needs to be done
When a patient is transferred to 6AS from one of the wards and remains under the teaching service, then that patient should be followed until either time of discharge/transfer or until they are transferred to the family medicine service. (As long as they are admitted under one of the teaching services, we should be following them)
When/if a patient is transferred to 6AS from a teaching service ward directly to 6AS but under a new teaching service then the collector responsible for that service will enter them as a new profile. Ie. If a patient is transferred from A service (E5) to 6AS but under C service, a new profile will be created on the 6E/5B laptop, the location should be 5B, and the patient should be considered a transfer from 5E to 5B
When a patient is admitted/transferred from 6AS to one of the teaching wards:
1. If they have remained under one of the teaching services and are transferred back to the same teaching service ward this should be one continuous admission and no new profile is needed 2. If they were under family medicine, then a new profile should be created under whichever teaching service they have been accepted to 3. If they were under a teaching service on 6AS and are transferred to a different teaching service then a new profile should be created by the collector who collects for that service. Ie. If a patient is admitted under C service on 6AS and is transferred to 5E, then a new profile should be created for 5E and the patient should be considered transferred from the 6E/5B laptop
Medicine Overflow Patients
See OVER for data entry info.
Process for identifying Overflow patients
- how do we find out about the patients? Template:Discussion
Who collects "OVERs"
- which laptop do these end up on? Template:Discussion
Original entry...
Template:Discussion The following is confusing because it deals with patients who spend part of their stay off ward. OVER is about patients who spent whole stay off ward. Do we use the notes mention of partial off ward stay in our data, Julie? If so we should formalize it. Parts of this likely are no longer true now that STB will do OVER. Ttenbergen 10:48, 2016 March 16 (CDT)
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. Please make a note in the "notes" section of the profile. There is no need to fill out any variables on the registration tab.
work load splitting
Serial_number#STB_5B:_Serial_number_share_plan Template:Discussion This is no longer split, right? Ttenbergen 16:28, 2016 March 14 (CDT)
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 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)
- Vacation relief for Elaine is covering E6 and B5 medicine. For Debbie, coverage is for E5.
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).
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.
- I didn't think we collected apache for medicine patients... what is this about? Ttenbergen 16:33, 2016 March 14 (CDT) Template:Discussion
Lab results
Lab results are now entirely online in the epr.