From CaisisWiki

Revision as of 17:50, 14 September 2009

Introduction

This guide was made in order to help new and current RSA’s efficiently and precisely enter prostate patient information from the clinic or surgery forms into Caisis in an approved and standardized method. This guide is also intended to enable other RSA’s who generally enter data for other urological cancers to be able to enter prostate patient data as well. In the event prostate data accumulates and RSA’s responsible for its entry are not able to enter it within four weeks other RSA’s can refer to this guide and assist in entering the data to ensure completion in a timely fashion. It is the goal of this guide to ensure a standard of prostate data entry and procedures for issues that may arise due to discrepancies on forms, medical records, and et cetera.

Follow Up and New Visit Forms

General Guidelines

When you are entering data from Caisis forms it is not always clear what the doctor has written especially in the Medications and Comorbidities sections. For these sections a good way to start is entering the first few letters in the data field until a list of possibilities drops down. If the dropdown list does not help solve the problem of interpreting hand writing, there are several tools available to you to determine what has been written.

One of the most important tools is the Electronic Medical Record (EMR). EMR is where you can find a scanned copy of forms and other documentation. Here you can zoom in on forms and try to take a closer look at the writing. Occasionally and depending on the doctor, you can find a dictation of the same form in EMR allowing you to easily understand what is written on the form. If you enter the first few letters or approximate spelling of a medication name and hit search, you can usually find the right spelling and a description of the medication.

For items written in the Medical & Surgical History / Comorbidities section doing a web search can provide clues to what the doctor wrote if you are not certain. Another great resource is of course your co-workers. Some RSA’s are used to an individual doctor's hand writing and may be able to help make out ambiguous items. If you are unable to definitively make out hand writing do not enter what you think it might say. Speak to your RDC or contact the person (ie. Attending or Fellow) who wrote down the items in question to find the answer.

Once you have entered data and want to save the form you need to always enter the Data Quality when it is available. You will have four options to select from. They are as follows:

• OUT - Occured outside the hospital with no documentation available in EMR, hearsay, patient reported data, (ie. Outside Lab Tests), procedures without documentation, E-mail sent by patient, telephone conversations, medications without original Rx order.
• REV - Source documentation reviewed at the hospital available in EMR under "OutsideCorres" folder, official reports such as path reports, lab reports, pathology specimens or slides reviewed at the hospital.
• STD - All original hospital documentation including dictated initial consults, clinic forms, diagnostic and pathology reports
• RR – Data reviewed for research by Attending Pathologist (Only for Prostate pathology results).

Allergies

Under the Patients tab click on Allergies. If "NKA" is checked on the form, then the patient has no known allergies. If the allergy or response listed is illegible on the form look in EMR if there is a dictation for that visit. Also, in the "ACHARTDOC" folder in EMR there will usually be a list of allergies and reactions.

Family History

Under the Patients tab click on Family Members. Only enter in family members who have/had cancer. The Relationship field must have a value entered, so if no relationship is stated use “Unknown”. If a relative has died from any type of cancer make sure to type it in the Notes section and include the age of death (ie. Died at age 72 of colon cancer).

Social History

Under the Patients tab click on Social History. Choose the type of Tobacco Usage from the drop down list. For entering the number of packs per day, use numbers to describe the amount. For example, a patient smokes an average 5 cigarettes a day (20 cigarettes per pack), so enter 0.25 packs per day. If a patient is described as only a social or occasional smoker, type either answer in the Pack per Day field. Sometimes a patient will have a smoking history that is not limited only to cigarettes. For these patients use the Other field (eg. Occasional marijuana use). Enter in the patient’s alcohol usage, carcinogen exposure and any other information that is supplied. The Data Source is always STD for social history.

Medical & Surgical History / Comorbidities

Under the Patients tab click on Comorbidities. Enter patient’s past medical histories in this form. It is important to note that past medical procedures are written in the same box on the clinic forms as Comorbidities. Make sure any procedures are entered in Procedures under the Procedure tab with the appropriate data quality entered. If there is no initial date, use “PreTx” meaning before treatment. Enter the Data Quality as OUT if there is no documentation besides the form for the comorbidity or procedure in EMR.

Medications

Under the Therapies tab click on Medications. Enter each medication and the date when the patient started taking it from the form, dictation, or medication reconciliation list. For a new visit or initial dictaion, if there is no date on any of these documents enter “PreTx”, meaning the patient began taking the medication prior to treatment. If a new medication is listed during a follow up visit, then enter the date of the visit as the start date for that medication. Many times medications are difficult to read so check if there is a dictation for that visit explaining the medications. You can also try entering the first few letters of the medication to generate a drop down list. Another option is to look up possible spellings of the medication on the web or in Lexi-Comp, which can be found under Tools in the CIS window. After completing tehe Date, Medication, Dose, and Schedule fields, select the appropriate Data Source (ie. Data Form / Medical Record / Medication Reconciliation) and Data Quality. If you do not have the original prescription order the Data Quality will be OUT.

Chemotherapy & Hormone Therapy

Under the Therapies tab click on Medical Tx. You must enter the Type of treatment, for example ‘Horm’ or ‘Chemo’, to be able to save the data. If available, always include the treatment Start Date and Stop Date as well as Dose and Route and Cycle if applicable. Some treatments will automatically select the Type (ie. Agent: Lupron; Type: HORM). If the chemotherapy was administered at MSK, you can open a patient's Pharmacy Profile under Tools in CIS to check dates, doses, and cycles.

Radiation Therapy

The two types of radiation therapy generally given to treat prostate cancer are External Beam Radiation and Brachytherapy. To enter External Beam Radation select "Radiation Tx" under the the Therapies tab. You must enter the Type of treatment to be able to save the data. If the type of radiation is unknown, select “Radiation Type, Unspecified” under the Type drop down box. Brachytherapy has its own form which you can select from the Therapies tab. When avaialable always include Start Date, Stop Date, Target, Type, Intent, Total Dose, # Fractions, Data Source, and Data Quality.

Biochemical Marker / Lab Tests

Under the Diagnostics tab click on Lab Tests. All lab tests done at MSKCC are automatically entered into Caisis. All outside PSA and related lab tests need to be entered from either clinic forms or outside reports in the "OutsideCorres" folder in EMR. Always check EMR if you are unsure whether a lab test is OUT or REV. It will be considered REV if the original outside lab report is in EMR.

Imaging

Under the Diagnostics tab click on Diagnostics. Enter all prostate related scans and any positive chest X-rays. When entering a scan done at MSKCC copy and paste the impression from the report in CIS into the Notes section. For outside scans available in EMR, type out the impression in the Notes section. Only enter Result if the attending physician has interpreted the scan and given a value on either a clinic form or dictation.

Common tests you will need to enter are CT scans, MRI's, Bone scans, TRUS, and PET scans. You do not need to enter anything in the sub-forms for any scans besides MRI’s and TRUS’s. Always enter Data Source and Data Quality.

MRI's

For MRI’s that use spectroscopy enter Type as "MRSI". For MRI’s that use an endorectal probe enter the Type as "eMRI". The prostate dimensions (Prostate Height, Prostate Width, and Prostate Length) need to be entered in the sub-form "Prostate Imaging", if they are provided in the findings. Make sure dimensions are entered in cetmeters and not milimeters.

TRUS (Transrectal Ultrasound)

Check the "Assessments" folder in EMR to look for any ultrasound forms. These need to be entered with the Type as "TRUS". Like a MRI enter the prostate dimensions in the "Prostate Imaging" sub-form. For the most part patients will have a TRUS performed in conjunction with a prostate biopsy. Prostate biopsies can be found in the "Pathology" folder in EMR. The result of the TRUS depends on whether or not the prostate biopsy found evidence of cancer or not. For all other scans only enter a result if the attending physician has interpreted the impression and given a value on either a clinic form or dictation.

Prostate Biopsies

To completely enter a prostate biospy you need to enter a procedure record, a pathology record using the outside institution's findings, and a pathology record using MSKCC's reviewed findings.

Procedure Record

Begin by selecting Procedures under the Procedures tab. Always enter the Date, Institution, Data Source and Data Quality. Data Quality will always be OUT for prostate biopsies done outside even if they have been reviewed and are avaialable in EMR. For the Procedure field you can enter "Needle Biopsy", "TRUS Biospy", or "TURP". Nearly all prostate biospies performed at MSKCC will be a TRUS biospy, containing a pathology report and TRUS data form in EMR. Most of the outside biospies will be Needle biopsies. Also be sure to enter "Prostate" in the Site field for each prostate biopsy.

Pathology Record(s)

Next under the Procedures tab go to the Pathology sub menu and select Prostate Biopsies. If a prostate biopsy is performed outside and it has been reviewed by a MSKCC pathologist, you will need to enter two pathology records; one from the outside report and one from MSKCC review. Make sure to connect each pathology record to the procedure record by choosing the corresponding Source Procedure in the drop down list.

For the top main portion of the form enter fields Path Report Date, Path # (aka Accession #), Specimen Type (same as the procedure name), Site, Result, Institution (where the specimen was reviewed), Pathologist, Data Source and Data Quality (Datat Quality is always OUT for data from outside reports). If the report was done or reviewed by Dr. Reuter enter RR (aka Reviewed for Research) for Data Quality

On the Prostate Biospy sub-form always enter the fields # Positive Cores, Total # Cores, # Positive Sites, and Total # Sites. If the biopsy has a Gleason Grade, enther the Primary and Secondary Gleason values as well as the Max % Cancer and Total Cancer Length fields. Other fields such as Atrophy, Prostatitis, ASAP, PIN, Perineural Invasion, and ECE only need to be entered if it was reported. If it was found select Yes or Present in the drop down list.

Next on Prostate Biopy Cores sub-from enter one row for every site sampled (eg. Right Medial Base). You only need to enter biopsy core details if the report originated at MSKCC or was reviewed by a MSKCC pathologist. For the # Cores field enter the total number of cores taken from that site. The rest of the fields are similair to the above Prostate Biopsy form and can be entered the same way using site specific data.

Surveys

Under the Encounters tab click on Surveys. On the clinic forms there is an area with surveys for Urinary and Sexual function. There are actually three different suveys in this area. One each for urinary and sexual function and another that is six questions convering both functions. Enter the responses to the six questions using the Short QOL Urinary and Sexual Function as the Type. For each question select the correspoding option under Survey Options. Enter the Result as the sum of questions (excluding number 4) out of the total of 27 (ie. 15/27). If nothing is filled out on the clinic form check EMR under the "Quality of Life" folder for the corresponding survey.

Next enter a survey for both urinary and sexual function selecting the corresponding Type. From the Survey Items list choose the items that have been filled in on the clinic form. Occasionally written on the clinic form there will be dates indicating when particular levels of function were achieved. If a survey has not already been entered for this written date, enter a new survey for the function using that date. Only select and enter data for either Continence or Sexual Function under Survey Items.

Always enter Data Source and Quality for each survey entered. The Data Quality will always be STD.

Encounters

Under the Encounters tab click on Encounters. Usually vitals are taken at the encounter and should always be entered when available.

Always enter an Encounter record with the Date, Type of visit, Chief Complaint (ie. Prostate Cancer or Bladder Cancer), Physician, Data Source and Data Quality for every data form or dictated visit you enter into Caisis. Usually vitals are taken at the encounter and should always be entered when available, especially Height and Weight.

Rectal Exam

Use the Rectal Exam sub form whenever a patient has a rectal exam performed. Any stage < T1c written with the exam should be entered as "Normal" for Result. Any stage >T2 should be entered as Abnormal "Malignant". For the exam fidings use the "Rectal Exam Findings" sub-form. The numbers used in the table are linked to the code below the table (ie. 5 = Definite Cancer).

Clinical Stage

Under the Encounters tab click on Clinical Stage. Only enter a clinical stage provided by MSKCC physicians. Select "Prostate" for Disease, "UICC_02" for Staging System, and the appropriate stage. Be sure to enter the Physician and Date. You can click on the T Staging button on the side to see what each stage identifies. Do not enter more than one stage if it is the same as the one already entered from an earlier date.

Disease State

Under the Outcomes tab click on Status. Always include the Date, Data Source and Data Quality along with the Status. The following are different status types:

Stable – Alive

NED – No Evidence of Disease

AWD – Alive with Disease

BCR – Biochemical Recurrence

LCR – Local Recurrence

Mets – Distant Metastasis

Also entered using the Status form is initial diagnosis date. This can usually be found on the new visit form or initial consult dictation. Select Diagnosis Date under the "Status" drop down list. Again, always enter the Date, Disease, Data Source and Data Quality.

Prostate Cancer Surgeries and Procedures

General Guidelines

To find the list of surgeries you are responsible for go to the prostate data entry folder on the share drive (H:\DataMgmt\ProstateDataEntry). Some attendings enter parts of the surgeries they perform directly into Caisis using e-forms. Others will fill out the surgery details form for you to collect and use to enter data. In either case you need to make sure the surgeries you are responsible for have been properly entered into Caisis with a lag time no greater than four weeks. You can find out whether or not you need to collect surgery detail forms by asking your RDC.

OR Details Record

The first step in entering any surgery is creating an OR Details record which can be found under the Procedures tab. If the Case Surgeon has already electronically completed an OR Details record you can enter additional data. Make sure the following fields have been entered into the OR Details form:

• Date
• Institution
• Case Surgeon - This is the surgeon who is peforming the primary procedure(ie. prostatectomy).
• Admit Date and Discharge Date - Found in the D/C Summary under the Discharge folder in EMR.
• Operating Time - Found in the OR Record under the Surgery folder in EMR.
• ASA and Anesthesia Type - Found in the Anesthesia Perioperative Report Part 2 under the Surgery folder in EMR.
• Estimated Blood Loss (EBL) and Fluids - Found in the Anesthesia Perioperative Report Part 1 under the Surgery folder in EMR.
• Difficulty - Provided by the surgeon on the surgery details form or dictation.
• Data Source
• Data Quality

Prostatectomy

To enter Prostatecomy specific data, select Prostatectomy on the sub menu under Procedures on the Procedures tab. Next connect the procedure record to previously created OR Details record. This is done by selecting the apprpiate OR Details record form the During Operation On drop down list. Make sure the following fields are entered for the procedure form:

• Date
• Procedure - Enter "RP" for Radical Prostatectomy, "LP" for Laparoscopic Prostatectomy, "RALP" for Robotic Assissted Laparoscopic Prostatectomy, "SalvRP" for Salvage Radical Prostatectomy, or "SalvLP" for Salvage Laparoscopic Prostatectomy
• Institution
• Surgeon
• Surgeon Type
• Data Source
• Data Quality

Prostatectomy Details

The Prostatectomy Details sub-form will appear below the main procedure record if you followed the instructions stated above. If the Prostatectomy Details sub-form is not on the same page as your previously entered procedure record, click on the "SubForms" button and select Prostatectomy.

Most of the information for this section can be found on the surgery detail forms filled out by the surgeons. If a surgery detail form or e-form has not been filled out, then you may not be able to enter all the required fields.

The following section/fields must be entered into corresponding fields in Caisis when available:

• Intraoperative Prostate Exam section
• UICC 1992 Stage
• Accessory Vessels section
• 1st Dissection of SV
• Bulldog Clamps
• Neurovascular Bundles section (Left and Right)
• Overall Sugery Difficulty
• Drains
• Catheter on Traction? section
• Vesicourethral Anastomosis section
  • Enter Quality of Bladder Sparing value as well as the Subjective Score of Urethral Stump value in the Suture Notes field (ie. Quality of Bladder Sparing = 4).
• PostOp Predictions - This section should be enetered as a new survey using the date of the surgery. For survey Type select "PostOp Predictions". For the Survey Items select Continence and Potency and enter percentage values.

Prostatectomy Findings

This sub form will appear below the main procedure record if you followed the instructions stated above. If it is not on the same page as your previously entered procedure record, click on the "SubForms" button and select Prostatectomy Findings.

This sub form corresponds to the section labeled Intraoperative Prostate Exam on the surgery details form filled out by the physician. Enter one row for each site mentioned on the form. The numbers printed on the form correspond to codes located to the left of the Intraoperative Prosate Exam box on the surgery details form.

Pathology

a) From Operation On

b) Source Procedure

c) Path Report Date

d) Path #

e) Specimen Type

f) Institution

g) Pathologist

h) Data Source

i) Data Quality(RR if Path report is done by Drs. Reuter or Olgac)

Prostatectomy Pathology

a) PIN Grade

b) Primary Gleason

c) Secondary Gleason

d) Margin Status

e) ECE

f) SV Inv

g) Perineural Inv

h) Vascular Invasion

i) BN Inv

j) Multifocal

Pathology Stages

a) Disease

b) Staging System - "UICC_97"

c) T Stage

Neural Stimulation (if applicable)

a) Side

b) Site

c) Level

d) Intensity

e) mA

f) Movement

Pelvic Lymph Node Dissection (PLND)

a) During Operation On - Select from top drop down box

b) Date - Same as Sx

c) Procedure - Enter "PLND"

d) Side - Usually performed bilaterally

e) Result

f) Data Source and Data Quality

PLND Pathology

Pathology Node Findings

a) Side

b) Site

c) Positive Nodes

d) Total Nodes