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

Medicine Overflow Patients

Some patients are admitted by medicine service but spend entire stay in into off-service beds throughout the hospital. See OVER#STB collection instructions for data entry info.

Process for identifying EMIP and Overflow patients

See EMIP for definitions and general collection information.

• We obtain our own lists of EMIP patients for medicine from the EPR. This is done by logging into EPR reports using your login that you use for initial computer log in. You then select 'pt list reports', then select 'discharge register', put in location 'ER' with the time frame that you wish to look at. You also need to put <ALL> in the attending provider spot. In the generated list, the patients that had been accepted by medicine will be indicated by the medical service in the list. Because the pt was discharged elsewhere but had been accepted by the medicine service, this defines the EMIP's. Some patients in the list may not be under medicine service, we do not use these. We run these results at least once a week. --LKolesar 13:32, 2016 October 26 (CDT)
• For overflows, you need to also use EPR reports, select 'pt list reports', then select 'transfer register' , location 'ER' and select 'from and to' for a selected time frame. You need to go over this list to see if any of the medical service patients went to an off-service ward. You do not put in the overflows right away because they may eventually be admitted to a medicine ward. If not, they will be considered an overflow. --LKolesar 07:58, 2016 October 27 (CDT)

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.

• • • the definition of an EMIP for the purposes of our database is a pt that is located in ER, gets accepted by medicine but never moves to any ward of that hospital. --LKolesar 08:32, 2016 November 3 (CDT)
      • Ah. Old definition. That's exactly why we should not have details addressed in other articles duplicated in the local instruction, they get left behind when these definitions change. See EMIP: "patients who are admitted to the medicine service and spend their entire admission under the medicine service in the ER". So, someone can be EMIP and then get admitted to ICU, where our ICU collectors should catch then, and would need to use e.g. STB_EMIP as previous location. The question is, how do we want to treat patients who are EMIP but then end up on a family or surgery ward? Will flag that for Julie and Trish. Ttenbergen 19:16, 2016 November 3 (CDT)
• When we do overflows (instructions how to retrieve this list on EPR are listed in this article above), then we see if these patients have been accepted to medicine (in ER) but have been put on a non-acute-medicine or non medicine service ward for their entire stay: this is the definition of an overflow. --LKolesar 07:50, 2016 November 4 (CDT)

See Overflow for definitions and general collection information.

Who collects "OVERs" and EMIP's

• 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). This way we will not miss any of the patients that are temporarily off the wards that we collect on. For these patients, do not use the overstay designation (OVZ)because that designation is only for those that never get a bed on E5, E6 or B5.

• 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 make a note in the "notes" section of the profile. There is no need to fill out any variables on the registration tab.

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. If there is use this as your date and time of discharge.

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

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)

• 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.
• 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)