From CaisisWiki

Current revision as of 19:54, 14 September 2009

Introduction

This guide was made in order to help new and current RSAs efficiently and precisely enter bladder patient information from the clinic or surgery forms into Caisis in an approved and standardized method. This guide is also intended to enable other RSAs who generally enter data for other urological cancers to be able to enter bladder patient data as well. In the event bladder data accumulates and RSAs responsible for its entry are not able to enter it within four weeks other RSAs 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 bladder 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.

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 RSAs 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 the Attending Pathologist

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 dictation, 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. After completing the 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 the hospital, you can open a patient's Pharmacy Profile under Tools in CIS to check dates, doses, and cycles.

Radiation Therapy

Under the Therapies tab you can select "Radiation Tx" or "Brachytherapy ". To enter External Beam Radiation 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 available 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 the hospital are automatically entered into Caisis. Outside lab tests can be entered from either clinic forms or outside reports in the "OutsideCorres" folder. 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 bladder related scans and any positive chest X-rays. When entering a scan done at the hospital 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, and PET scans. You do not need to enter anything in the sub-forms for these scans. Always enter Data Source and Data Quality.

Transurethral Resection of Bladder Tumor (TURBT)

• Date
• Path #
• Type
• Surgeon
• Result
• Stage System
• Stage T
• Grade
• Cis
• Histology
• Vascular Invasion
• Pathologist
• Institution
• Data Source
• Data Quality

Cystoscopy/Endoscopy

• Date
• Type
• Result
• Surgeon
• Stage T
• Surgeon
• Institution
• Data Source
• Data Quality

Encounters

Under the Encounters tab click on Encounters. Always enter the Date, Type of visit, Chief Complaint (eg. Prostate Cancer or Bladder Cancer), and Physician 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.

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.

Bladder Cancer Surgeries and Procedures

General Guidelines

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.
• 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

Procedure Record

To enter bladder specific data, select Cystectomy 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 appropriate 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 "Radical Cystectomy", "Partial Cystectomy", "CP" for Radical Cysto-Prostatectomy, "Salvage Radical Cystectomy", or "SalvCP" for Salvage Radical Cysto-Prostatectomy
• Site
• Institution
• Surgeon
• Surgeon Type
• Data Source
• Data Quality

Cystectomy Details

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

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:

Pathology Record

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

Cystectomy Pathology

Pathology Stages

a) Disease

b) Staging System - "UICC_02"

c) T Stage