Digital Innovation, Inc. Report Writer Standard Reports Dictionary 2017

Transcription

1 Digital Innovation, Inc. Report Writer Standard Reports Dictionary

2 Proprietary Rights Notice The Digital Innovation, Inc. Trauma Registry Software and related materials, including but not limited to this document, and other written material provided by Digital Innovation, Inc. (collectively Software Products ) constitute confidential and proprietary information of Digital Innovation, Inc. It is the responsibility of the user to comply with all applicable copyright laws. The Software Products are to be maintained in confidence and not to be disclosed, duplicated, or otherwise reproduced, directly or indirectly, whole or in part, or any materials relating thereto, except as specifically authorized by Digital Innovation, Inc. No portions of this manual may be reproduced, duplicated, or disclosed without the expressed written approval of Digital Innovation, Inc. Reasonable steps are to be taken to ensure that no unauthorized persons have access to the Software Products and that all authorized persons having access to the Software Products refrain from any such disclosure, duplication, or reproduction except as authorized by Digital Innovation, Inc. Copyright Digital Innovation, Inc. All Rights Reserved The referenced Trauma Registry Software is developed and maintained by Digital Innovation, Inc., PTSF s Technology Partner. The Trauma Registry Software screenshots included in this presentation are from Digital Innovation, Inc. s product suite. 2

3 Contents Proprietary Rights Notice... 2 Report Writer (RW) Standard Reports... 5 Audit Filters... 6 Audit Filter Missing Data... 7 Anatomical Diagnoses Report... 8 Anatomical Diagnoses Report with Payor Data... 9 Burn Unexpected and Exclusions Census Report Central Site Min Checks Bad Date Report Central Site Min Checks Report Data Completeness Data Completeness (Part 1. Demographics) Data Completeness (Part 2. Prehospital) Data Completeness (Part 3. Acute Care) Data Completeness (Part 4. Clinical) Data Completeness (Part 5. Outcome) Data Completeness (Part 6. Burn Data) Data Completeness (Part 7. Procedures) Data Form Facsimile (Complete) Data Form Facsimile (Complete w/as Text) Data Form Facsimile (State Elements Only) Demographics Report Discharge to Destination Dump Procedures to CSV Frequency of Admissions to the ED by Hour/Day of Week Frequency Report Functional Status at Discharge Report Hospital Length of Stay by ISS and Provider Responding to ED Injury List Report Injury Severity by Provider Responding to ED

4 Length of Stay in ED by Hour of ED Admission List of Elapsed Time from ED Admission to First OR Visit LOS Statistics Report Occurrences by Day of Week Patient Record List Pediatric Mechanism of Injury Report Peer Review Reports Peer Review Summary PI Summary (Level IV PI) Post ED Destination PRE Charts PRE Charts with Extended Outcome Evaluation PTSF Time Sequence Report Research Download ED Response Time by Provider Scores Report Burn Patients Scores Report Trauma Patients Site Survey Medical Record List Site Survey Report Pediatric Patient Disposition Site Survey Report Spleen Injury Procedure Rates Site Survey Report Time to Procedure for SDH or EDH Site Survey Report Trauma Alert Upgrades Transfer In/ Transfer Out Report Volume/Utilization Report z and W Scores Reports (All Models) PIRIS Data Submission PIRIS Summary

5 Report Writer (RW) Standard Reports There are fifty-five (55) Standard Reports in Report Writer for use by trauma centers. These include Data Table and Statistics reports. Most of these reports use the same Specify Records Criteria which allows searching data by Emergency Department Admission (EDA) dates or by Trauma Number. Standard Specify Records Criteria Seven (7) reports have additional tabs for Selection Criteria while three (3) reports use a different, limited search function. Reports with criteria other than the standard will be noted within each individual report description. Please note that screenshots may contain all or a portion of the report. 5

6 Audit Filters Report criteria contains a second tab, Include Filters, with options to include/exclude individual filters. Click Pg down to view/choose each filter. Lists all patients within set parameters that meet criteria for each Audit Filter. Shows count and percent for each filter. Lists each trauma record with pertinent information for the filter. o (23 filters in 2017, will change in 2018) Shows count/percent of number of records unable to be assessed for filter due to missing data. Includes a summary of all records meeting any audit filter (count, percent and listing of each). 6

7 Audit Filter Missing Data Report criteria includes a second tab, Include Filters, with options to include/exclude individual filters. Click Pg down to view/choose each filter. Gives the count and percent of records unable to be assessed for each filter. Lists each record that meets the filter with pertinent information. 7

8 Anatomical Diagnoses Report Currently includes ICD-9 diagnosis code. Lists the AIS codes, ICD-9 codes and injury text for each record. Includes ISS, LOS, age and Discharge Status. Includes injury date/time, but not EDA, so potentially no date/time info. Includes cause of injury specify text field, but not ICD-9/10 code. 8

9 Anatomical Diagnoses Report with Payor Data Currently includes ICD-9 diagnoses codes. Same report as Anatomical Diagnoses Report including Payor Data. Lists the AIS codes, ICD-9 codes and injury text for each record. Includes ISS, LOS, age, and Discharge Status. Includes injury date/time, but not EDA, so potentially no date/time info. Includes cause of injury specify text field, but not ICD-9/10 code. 9

10 Burn Unexpected and Exclusions Uses ICD-9 diagnosis codes for burn and inhalation injury inclusion. Counts total burns by survivors, deaths, and unknown status. Count predicted or outliers for deaths/survivors and show count excluded due to missing data. 10

11 Census Report This report has limited search criteria. One month and year selected and compared to the same month of the previous year. There is an option for output to a CSV file. Daily census by day and date, one-month period. Includes total and average daily census. 11

12 Central Site Min Checks Bad Date Report Identify records with any date entry that is outside batch date. (3-month period of submissions) Please correct the following records which have dates beyond the current date. Inst-Trauma EDA_DATE 01/01/2018 D_C_DATE 01/04/2018 Central Site Min Checks Report Lists errors in entry such as mismatch between Discharge Destination and Discharge Status, Unknown or missing fields, incorrect AIS version, etc. Confidential - For Peer Review Purposes Only Incorrect AIS Version AIS Version is AIS 90 EDA Date is: 01/01/2018 Mismatch: Post ED Destination is Morgue (Coroner, Death, DOA) Discharge Status is: Alive Unknown Discharge Status Unknown Date of ED Admission Mismatch: Discharge to Destination is Home Discharge Status is: Dead 12

13 Data Completeness Cause of injury currently listed as ICD-9 code range. Place of Injury and Activity codes based on ICD-9. Protective devices rules based on ETIOLOGY/ICD-9 Referring Facility Therapeutic/Diagnostic Interventions, and Procedures based on ICD-9 codes. Counts numerical/text and drop-down responses for elements in the trauma record. All possible responses for each element are counted including those left blank. This type of review does not include Injury Diagnosis code or individual Procedure code entry. For injury diagnosis information, consider Anatomic Diagnosis Report. The Frequency Report may be run for Injury Diagnosis or Procedure code among other choices. This is a very long report, 60+ pages. For convenience or more focused review, this report is also divided into seven sections which may be run as individual reports. Part 1. Demographics Part 2. Prehospital (includes the Prehospital and Referring Facility tabs) Part 3. Acute Care Part 4. Clinical Part 5. Outcome Part 6. Burn Data (includes elements from the Burn Dx, Lund and Browder subcategories under Diagnosis Tab.) Part 7. Procedures (includes Payor information) See the individual reports for more detail and screen shots. 13

14 Data Completeness (Part 1. Demographics) Cause of injury currently listed as ICD-9 code range. Place of Injury and Activity codes based on ICD-9. Protective devices rules based on ETIOLOGY/ICD-9. Count and percent of responses for elements in the Demographics tab. Counts possible responses in drop-down menus for each element as well as those left blank. Includes patient and injury information and Preexisting Conditions. 14

15 Data Completeness (Part 2. Prehospital) Referring Facility Therapeutic/Diagnostic Interventions based on ICD-9 codes. Count and percent of responses for elements in the Prehospital and Referring Facility tabs. Counts possible responses in drop-down menus for each element as well as those left blank. The Prehospital tab includes information on Scene Provider and Transport Provider. The Referring facility tab includes procedures, vitals, and other information from the facility and Interhospital Provider. 15

16 Data Completeness (Part 3. Acute Care) Count and percent of responses for elements in the Acute Care tab. Counts possible responses in drop-down menus for each element as well as those left blank. 16

17 Data Completeness (Part 4. Clinical) Count and percent of responses for elements in the Clinical tab. Counts possible responses in drop-down menus for each element as well as those left blank. Includes On Admission Vitals and Alcohol and Drug Screen information. Also includes Nutrition elements which are only required for Burn Patients at Burn Centers. 17

18 Data Completeness (Part 5. Outcome) Count and percent of responses for elements in the Outcome tab. Counts possible responses in drop-down menus for each element as well as those left blank. 18

19 Data Completeness (Part 6. Burn Data) Count and percent of responses for elements in the Burn Dx and the Lund and Browder subcategories under the Diagnosis tab. Counts numeric/text entries and possible responses in drop-down menus for each element as well as those left blank. 19

20 Data Completeness (Part 7. Procedures) Procedures based on ICD-9 codes. Count and percent of responses for elements in the Procedures tab. o Does not list individual Procedures entered, but counts responses to the other fields in this section. Counts possible responses in drop-down menus for each element and those left blank. Also includes Payor Information elements from the Miscellaneous tab. 20

21 Data Form Facsimile (Complete) Everything entered into the record. Drop-down multiple selections are listed by character (1,2,3, etc.) Note: Facility reports will include all entered data including optional, custom fields and identifiable data not transmitted to Central Site. 21

22 Data Form Facsimile (Complete w/as Text) Everything entered into the record with drop-down options written out as text. Note: Facility reports will include all entered data including optional, custom fields and identifiable data not transmitted to Central Site. 22

23 Data Form Facsimile (State Elements Only) Everything entered into fields that transfer to the state (yellow and blue fields). 23

24 Demographics Report Cause of Injury based on MTOS Etiology/Other Etiology, diagnosis based on ICD-9 codes. Includes ranges of ISS, age, RTS, and Outcome information. 24

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26 Discharge to Destination Cause of Injury based on MTOS Etiology/Other Etiology, diagnosis based on ICD-9 codes. Lists count of patients by Discharge Destination. Various information on each discharge destination such as ICU LOS, Type and cause of injury are included. 26

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28 Dump Procedures to CSV Cause of injury currently reported as ICD-9 code. Procedure codes report in both ICD-9 and ICD-10 and selection procedure criteria is based on ICD-10. Report criteria includes a second tab, Specify Procedures. Search may be limited to certain codes or ranges, specific location, service, or procedure, among other variables. There is a selection of additional elements which may be included. This report lists procedures performed. A Comma-Separated Values (CSV) file is created. See report on next page 28

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30 Frequency of Admissions to the ED by Hour/Day of Week Count of ED admissions by hour and day of the week. 30

31 Frequency Report Report criteria includes a second tab, Report Options, with a number of options to Count in descending order: Diagnoses (ICD-9 or 10), Procedures (ICD-9 or 10), Mechanism of Injury Primary and Secondary codes (ICD-9 and 10), Procedures in OR (ICD-9 only), Consults, Pre-existing, Occurrences. [See WHICH LIST options below.] These can be counted as total number, or sorted by: Age ranges, ISS, Survivors/Deaths, TRISS Survivors/Deaths, by month or by quarter. [See WHICH COLUMN options below.] Criteria drop-down options shown below followed by examples. 31

32 WHICH LIST options (Count) WHICH COLUMN options (Sort) SHOW CODES 32

33 This report opens in EXCEL when run to Screen. Examples shown using various elements counted (WHICH LIST) with total number or sorted (WHICH COLUMN) 33

34 Functional Status at Discharge Report Count of patients with specific FSD score, sorted out by blunt vs. penetrating injury, and then by ISS range. 34

35 Hospital Length of Stay by ISS and Provider Responding to ED Count and Average LOS by ISS ranges (including Not Valued) and provider. 35

36 Injury List Report Report criteria includes two additional tabs, Injury Specifications and Patient Details. Injury specifications tab includes option to enter specific ICD-9 codes or ranges, or match whole/partial ICD-10 codes. [See OPERATOR options.] You may also search by AIS codes/ranges, or AIS Severity less than or greater than a user defined value. Patient Details tab includes numerous elements to include/exclude. 36

37 This report lists injury code selected and description (choose ICD-9, ICD-10, AIS predot and/or severity) Opens in EXCEL when run to screen Note: Each injury code is assigned separate line, may have multiple lines per patient. 37

38 Injury Severity by Provider Responding to ED Count with average ISS and standard deviation per provider type. 38

39 Length of Stay in ED by Hour of ED Admission Statistical information for ED Length of Stay (LOS) measured in minutes. 39

40 List of Elapsed Time from ED Admission to First OR Visit Query searches for first valued ICD-9 code. EDA event, Initial OR event, and Elapsed time days/hours/minutes for each patient with OR visit. Note the procedure with missing date/time. In the record submitted, date is entered but time is missing. For this report, they are pulled as a single element, but even if date was listed, the elapsed time cannot be calculated without the operative time. 40

41 LOS Statistics Report Count, Average and Standard Deviation of patient LOS for: o ED hours o Hospital days o Step-down days o ICU days o Ventilator days. Sorted out by Injury type. 41

42 Occurrences by Day of Week Count of PTOS defined Occurrences by days of the week. Note: Occurrences are (almost) listed alphabetically. Pressure Ulcer (previously Decubitus) is in order where Dec would be ordered alphabetically. 42

43 Patient Record List List of all records in Search criteria showing Active or Closed status Note: Example from Central Site only sees PTOS records submitted, always listed Active, Never Transferred. 43

44 Pediatric Mechanism of Injury Report Cause of injury codes are ICD-9. Count of Mechanism of Injury for Pediatric patients by age ranges. 44

45 Peer Review Reports Diagnoses and Procedures codes are reported in ICD-9. Mechanism of Injury specify (not code), Diagnoses, Procedures, Occurrences listed for each record within the Specify Records criteria. In records of patient deaths, notes if Autopsy Results available. 45

46 Peer Review Summary Diagnoses and Procedure codes are reported in ICD-9. Lists Mechanism of Injury specify (not code), Injury Diagnoses and Procedure codes for each patient within the Specify Record Criteria. Does not include Occurrences or Autopsy information as included on the Peer Review Report. 46

47 PI Summary (Level IV PI) PI Summary previously used by Level IV centers is still available for use Level IV now use POPIMS. Inst# 9999 Trauma# Medical Record# Name: doe, john Age: 50 in Years Sex: Male ISS: 9 TRISS: Arrival: 01/01/2018 : Discharge: 01/04/2018 : Discharge Status: Alive Performance Improvement and Patient Safety PI Item: Airway Management (Prehospital) Opened: 01/01/2018 Referred To: None Loop Closure: Closed, Tagged for Follow-up Issue Closed: 12/08/2017 Action Plan: Education Completed: 01/07/2018 Responsible Person: Action Plan - Details: Action plan detailed notes... Action Plan - Outcome/Result: Outcome result notes... 47

48 Post ED Destination Cause of Injury based on MTOS Etiology/Other Etiology, queries based on ICD-9 codes. Lists count of patients by Discharge Destination. Various elements on each discharge destination such as ICU LOS, Type and cause of injury are included. 48

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50 PRE Charts Uses standard TRISS which is based on ICD-9 diagnoses codes. Identify unexpected outcomes [Survivors/Deaths] by: o Adults aged years with blunt injury o Adults aged 55 years and up with blunt injury o Adults aged years with penetrating injury o Adults aged 55 years and up with penetrating injury o Pediatric patients (aged 14 years and younger). Patient records with unexpected outcomes listed by trauma number with patient scores. 50

51 PRE Charts with Extended Outcome Evaluation PRE Charts with EOE are based on TRISS EOE. Tables include TRISS EOE, A, B, C, and D Scores and ASCOT EOE based on ICD-9 diagnoses codes. 51

52 PTSF Time Sequence Report Cause of Injury and Procedures in narrative are reported in ICD-9 codes. Prehospital times and scene time (if applicable), EDA and ED LOS, Provider alert and arrival, in minutes. Hospital LOS, Occurrences elapsed time from EDA, Consults elapsed time from EDA in days. Procedure date/time listed, no elapsed time. Includes cause of injury, payor information and pre-existing conditions. Note: Diagnoses narrative text is listed, no codes or code descriptions. Procedures are listed by code description. 52

53 Research Download Report includes ASCOT which is based on ICD-9. Otherwise updated to ICD-10. Note: This is an extensive report with many elements. There are two documents designed to accompany this report. Research Download Contents is a pdf file which explains the contents of the fields. Research Download Elements 2017 is a spreadsheet which explains the elements you are reviewing. If you do not have these documents, you may request copies from PTSF. Report criteria has a second tab, Optional Sections, allows inclusion of Prehospital elements. Run report to Screen. Two reports are generated to the root file of Collector. 53

54 First report is Download Log File: Lists trauma numbers, EDA and Hospital Discharge date for each record included. The second report is a CSV file with the elements on each file. The format allows you to save in EXCEL, sort and filter as desired. A very small portion of the file is shown in this screenshot. 54

55 ED Response Time by Provider Statistics on ED Response time measured in minutes. Lists Providers with separate fields on ED Response tab. 55

56 Scores Report Burn Patients Queries based on ICD-9 diagnosis codes. Patient scores with Probability of Survival and Unexpected outcome reported. 56

57 Scores Report Trauma Patients Queries based on ICD-9 diagnosis codes. Patient scores with Probability of Survival and Unexpected outcome reported. 57

58 Site Survey Medical Record List Report criteria includes a second tab, Specify Survey List, with option of one (1) week or three (3) week list. Includes Trauma number, Medical Record Number, and Patient name. 58

59 Site Survey Report Pediatric Patient Disposition Count and Average time for Pediatric Patient disposition. Includes individual trauma records with injury type, ISS, TRISS and Elapsed time EDA to Post ED in hours/minutes. 59

60 Site Survey Report Spleen Injury Procedure Rates Procedure codes are reported in ICD-9. Search parameter diagnosis codes are ICD-9 only. Provides count/percent of procedures performed on patients with spleen injury. 60

61 Site Survey Report Time to Procedure for SDH or EDH Procedure code description is listed (not codes.). Search parameter diagnosis codes are ICD-9 only. Provides information on patients with diagnosis of Cerebral EDH or SDH and craniectomy/craniotomy procedure, including elapsed time from arrival to procedure. 61

62 Site Survey Report Trauma Alert Upgrades Provides information on patients with upgraded alerts, including elapsed time from arrival to upgrade, discharge status, and ISS. 62

63 Transfer In/ Transfer Out Report Includes Length of Stay information (dates/times), payor information and Discharge Status. Sorted by: o Patients transferred in with Referring Facility LOS greater than 3 hours. o Patients transferred out with Hospital LOS greater than 3 hours. 63

64 Volume/Utilization Report Mechanism of Injury based on ICD-9 codes. This report has limited search criteria, enter one month and year. Includes an option for output to a CSV file. Count trauma patients in review with count and percent of PTOS patients. Numbers in specified month and year to date, compared to same data of previous year. See example on next page. Note: Example includes only PTOS patients at Central Site; may include NPTOS at facility. 64

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66 z and W Scores Reports (All Models) Model queries are based on ICD-9 diagnosis codes. Report Criteria includes a second tab, Sect 2, to choose Probability of Survival [P(s)] Model. Runs P(s) models selected. 66

67 PIRIS Data Submission This data submission had specific selection criteria. Limited trauma centers participated in this data collection. Note: This does not generate a report; it is selection of records for submission into PIRIS data collection. 67

68 PIRIS Summary Provides count of records marked Submit to PIRIS, and listing of records that meet the PIRIS criteria but not submitted. PIRIS Criteria includes ICD-9 E-code range and injury text for GSW. Limited number of trauma centers participated in this data collection. 68