Emergency Department Information System (EDIS) – Data Validation

Canberra Hospital and Health Services

Operational Procedure

Emergency Department Information System (EDIS) – Data Validation

Contents

Contents1

Purpose2

Scope2

Section 1 – Preparation of Validation Reports2

Implementation3

Related Policies, Procedures, Guidelines and Legislation4

References4

Search Terms4

Attachments4

Attachment 1: Daily Data Validation Reports6

Attachment 2: Triage Category waiting time exceeded7

Purpose

For 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.

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Scope

This Operational procedure applies to the EDIS Administrators only. EDIS administrators are employed by ACT Health within the division of Critical Care

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Section 1 – Preparation of Validation Reports

1. Run, 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.

2. 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 reports

3. After 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’

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:

a. Time seen as recorded in patient notes

b. Time 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.

c. 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)

d. The earliest time of a written medication or fluid order signed by a doctor

e. Correction of obvious errors (incorrect day, 12-hour versus. 24-hour clock, etc.)

f. Comprehensive completion of the triage mental health checklist if all responses marked as ‘No’

g. Earliest entry by mental health clinician on MAJICeR

h. Earliest recorded doctor time on EDIS (Ctrl+H)

5. Any differences are recorded on the hard copy of the ‘Excess Triage Category Wait Report’ (See Appendix B).

6. The documented differences are then used to edit the ‘Doctor Seen By’ time in EDIS.

7. When the editing is complete re-run and save the:

a. ‘Excess Triage Category Wait’” Report and save;

b. ‘Triage Excess Percentage’ report and print.

8. 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 Measure

Accurate 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”

Method

My Hospitals:

· Waiting Times

· Time in Emergency

· Number of Patients

Score Card

ED Validation Report

National & Local KPI’s

Performance Information Portal – ED Live

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Implementation

This document will be Available on the policy register on Sharepoint, discussed at orientation and in existing program of education for EDIS administrators

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Related Policies, Procedures, Guidelines and Legislation

Legislation

ACT Health Records (Privacy and Access) Act 1997

Electronic Transactions ACT 2001

Territory Records Act 2002

Policies

Data Quality Policy

System Security Plan: EDIS – Emergency Department Information System

Data Release Policy

Acceptable Access and Use of Information Technology (IT) Policy

Data Custodian and Data Steward Policy

Electronic Emergency Department Operating System (EEDOS) Policy

Standards

ACT Health Admitted Patient Activity Data Standards

Non-Admitted Patient Emergency Department Care NMDS 2014-15

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References

1. ACT Auditor-General’s Performance Audit Report

2. Emergency Department Performance Information, Report No.6/2012, July 2012

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Search Terms

EDIS, Data, Emergency Department Information System, Validation, Waiting times

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Attachments

Attachment 1: Daily Data Validation Reports

Attachment 2: Triage Category waiting time exceeded

Disclaimer: 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 Amended

Section Amended

Divisional Approval

Final Approval

14/03/2018

Full review

ED, Critical Care

CHHS PC

This document supersedes the following:

Document Number

Document Name

Attachment 1: Daily Data Validation Reports

· Referred from ED

· Downtime List

· Referred by

· DOH Error Report

· Patients Located in EMU

· NE check

· No EPISI

· LMO Code Blank

· ADMEPISI1

· Short EMU Admissions

· Bed Req – Depart Mismatch

· Doctor Specialty Mismatch

· Depart Dest – Ward Mismatch

· Overlapping Episodes

· Deaths

Incomplete Admissions List

· DUP2

· EDIS Edits Prior to 48 Hours After Discharge

· Did Not Wait

· Date-Time Mismatch

· Ward Comparison Folder

Refer to the EDIS Administrator Local Procedure Manual located in the EDIS Administrator office for further details on these reports.

CHHS18/114

·

Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHHS18/114

1.0

16/03/2018

01/07/2019

Critical Care

7 of 7

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

Attachment 2: Triage Category waiting time exceeded