Emergency Department Information System (EDIS) – Data ...



Canberra Hospital and Health ServicesOperational Procedure Emergency Department Information System (EDIS) – Data Validation Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc508267927 \h 1Purpose PAGEREF _Toc508267928 \h 2Scope PAGEREF _Toc508267929 \h 2Section 1 – Preparation of Validation Reports PAGEREF _Toc508267930 \h 2Implementation PAGEREF _Toc508267931 \h 3Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc508267932 \h 4References PAGEREF _Toc508267933 \h 4Search Terms PAGEREF _Toc508267934 \h 4Attachments PAGEREF _Toc508267935 \h 4Attachment 1: Daily Data Validation Reports PAGEREF _Toc508267936 \h 6Attachment 2: Triage Category waiting time exceeded PAGEREF _Toc508267937 \h 7PurposeFor various reasons, there are inconsistencies in the information entered in the Emergency Department Information System (EDIS). As a result, data validation is required. This Operational Procedure provides guidance to the EDIS System Administrators on which records to audit and which data they are allowed to edit in EDIS.Back to Table of ContentsScopeThis Operational procedure applies to the EDIS Administrators only. EDIS administrators are employed by ACT Health within the division of Critical CareBack to Table of ContentsSection 1 – Preparation of Validation ReportsRun, save and print the following reports DAILY:‘Excess Triage Category Wait’ and ‘Triage Excess Percentage’The timeframe for these reports are for the previous day, from midnight to midnight.Next, run the other 21 data validation reports (see Attachment 1) which identify other data entry inconsistencies. Save any reports that flag incorrect data before any data validation is made. The timeframe for these reports are also for the previous day, from midnight to midnight. Edit all incorrect data identified in these reportsAfter the data has been corrected, re-run and print the ‘Excess Triage Category Wait’ Report. This report is used to review the ‘Doctor Seen By’ times. Apply the following parameters:Exclude ‘Did Not Wait’Exclude ‘Triage Category 4’The EDIS Administrator is required to review the clinical records of every patient on the list. Any one of the following list of documented evidence may be used to edit the ‘Doctor Seen By’ times:Time seen as recorded in patient notesTime of arrival for Triage Category 1 patients sent into Resuscitation – Code Trauma, Air Ambulance Retrieval, Intubated, Cardiorespiratory Resuscitation (CPR) in progress and straight to Resuscitation.Time of commencement of a medically approved and supervised protocol (Chest Pain Pathway, etc.)? For patients seen as part of the Chest Pain Pathway or where an ECG has been performed in the initial assessment, the recorded time of the Electrocardiograph (ECG) (following the protocol that all ECGs are to be shown immediately to a senior Emergency Department (ED) doctor for assessment)The earliest time of a written medication or fluid order signed by a doctorCorrection of obvious errors (incorrect day, 12-hour versus. 24-hour clock, etc.)Comprehensive completion of the triage mental health checklist if all responses marked as ‘No’ Earliest entry by mental health clinician on MAJICeR Earliest recorded doctor time on EDIS (Ctrl+H)Any differences are recorded on the hard copy of the ‘Excess Triage Category Wait Report’ (See Appendix B).The documented differences are then used to edit the ‘Doctor Seen By’ time in EDIS.When the editing is complete re-run and save the:‘Excess Triage Category Wait’” Report and save;‘Triage Excess Percentage’ report and print.Store the hard copies of before and after Triage Excess Percentage reports and the printed audit template with documented changes in ‘this month’s data’ folder. Audit records are only kept for about 3 months and sent to Records Management at Mitchell for secure storage, these reports are only retrieved if requested through an official inquiry process.Outcome MeasureAccurate recording, or as close to, of the management of patients who attend the ED. The intention of this procedure is to ensure accurate recording or management of patients who attend the ED. Compliance with this procedure is monitored using [methods listed below”MethodMy Hospitals:Waiting TimesTime in EmergencyNumber of PatientsScore CardED Validation ReportNational & Local KPI’sPerformance Information Portal – ED LiveBack to Table of Contents Implementation This document will be Available on the policy register on Sharepoint, discussed at orientation and in existing program of education for EDIS administrators Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislationACT Health Records (Privacy and Access) Act 1997Electronic Transactions ACT 2001Territory Records Act 2002PoliciesData Quality PolicySystem Security Plan: EDIS – Emergency Department Information SystemData Release PolicyAcceptable Access and Use of Information Technology (IT) PolicyData Custodian and Data Steward PolicyElectronic Emergency Department Operating System (EEDOS) PolicyStandards ACT Health Admitted Patient Activity Data StandardsNon-Admitted Patient Emergency Department Care NMDS 2014-15 Back to Table of ContentsReferencesACT Auditor-General’s Performance Audit ReportEmergency Department Performance Information, Report No.6/2012, July 2012 HYPERLINK \l "Contents" Back to Table of ContentsSearch Terms EDIS, Data, Emergency Department Information System, Validation, Waiting timesBack to Table of ContentsAttachmentsAttachment 1: Daily Data Validation ReportsAttachment 2: Triage Category waiting time exceededDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 14/03/2018Full reviewED, Critical CareCHHS PCThis document supersedes the following: Document NumberDocument NameAttachment 1: Daily Data Validation ReportsReferred from EDDowntime ListReferred byDOH Error ReportPatients Located in EMUNE checkNo EPISILMO Code BlankADMEPISI1Short EMU AdmissionsBed Req – Depart MismatchDoctor Specialty MismatchDepart Dest – Ward MismatchOverlapping EpisodesDeathsIncomplete Admissions List DUP2EDIS Edits Prior to 48 Hours After Discharge Did Not WaitDate-Time MismatchWard Comparison FolderRefer to the EDIS Administrator Local Procedure Manual located in the EDIS Administrator office for further details on these reports.Attachment 2: Triage Category waiting time exceeded ................
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