CMS844 & CMS529-earliest electronically documented sbp in the encounter- intra-op documentation

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    • Type: Logic/Intent/Data Elements
    • Resolution: Unresolved
    • Priority: Moderate
    • None
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      To ensure the earliest CCDEs are available for mapping in an electronic record, should all documents that are available in the electronic record (excluding scanned documents) be considered for CCDEs within the specified timeframe?
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      To ensure the earliest CCDEs are available for mapping in an electronic record, should all documents that are available in the electronic record (excluding scanned documents) be considered for CCDEs within the specified timeframe?
    • Cari Jones
    • 4054738842
    • INTEGRIS Healthcare

      A particular patient went through surgery before being admitted as an IP. In the anesthesia record, VS from that procedure are listed in a hyperlink (not a flowsheet) titled "Intra-op Flowsheet Data." When the hyperlink is selected in EPIC, it takes the viewer to a page that just includes (among other things) a list of vital signs with the corresponding times the vitals were taken/recorded.

      1)Is there a limit to the type of document the information can be pulled from (excluding scanned documents)?

      2)does it matter how the vitals are labeled? for example, in EPIC, flowsheets label a blood pressure "BP" and in the "intra-op flowsheet data" information blood pressures are labeled "NIBP."

            Assignee:
            CHM Admin User
            Reporter:
            Cari Ann Jones
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              Created:
              Updated: