Data Entry Guide Part2

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Contents 1 Patient Data Pull Down Menu Forms Explained 1.1 Patients Drop List 1.1.1 Patients -> Summary 1.1.1.1 Narratives 1.1.2 Patients -> Demographics 1.1.3 Patients -> Actions 1.1.4 Patients -> Allergies 1.1.5 Patients -> Categories 1.1.6 Patients -> Patient Consent 1.1.7 Patients -> Comorbidities 1.1.8 Patients -> Dietary Intake 1.1.9 Patients -> Family Members 1.1.10 Patients -> Identifiers 1.1.11 Patients -> Physicians 1.1.12 Patients -> Protocols 1.1.12.1 Adding and Editing Protocols 1.1.12.2 Protocol Status Subform 1.1.13 Patients -> Social Histories 1.2 Encounters Drop List 1.2.1 Encounters -> Encounters 1.2.1.1 Physical Exams SubForm 1.2.1.2 Rectal Exam SubForm 1.2.1.3 Bimanual Exam SubForm 1.2.1.4 Review of Systems SubForm 1.2.2 Encounters -> Clinical Stages 1.2.3 Encounters -> Surveys 1.2.3.1 Adding New Surveys 1.3 Procedures Drop List 1.3.1 Procedures -> Surgeries 1.3.1.1 The Surgeries Subforms 1.3.1.1.1 Prostatectomy Op SubForm

Patient Data Pull Down Menu Forms Explained

Each of the navigational menus contains pull-down options that display a form on the right side of the screen to either review existing data or enter new data. Each of the menu selections filters the DVV list to display items related to your selection. Selecting an item from the DVV list will display its details on the form on the right side of the screen. You may edit existing records, add new records, lock records from editing, and delete records. Pictured below are the expanded Patient Data pull-down menus.

The Expanded Patient Data Pull Down Menus

Patients Drop List

Patients -> Summary

Selecting Summary from the Patients menu returns you to the first screen visible on the Patient Data tab. This form contains physician narratives and summaries of the patient’s allergies, comorbidities, diagnoses, and medications. Selecting Summary also refreshes the DVV list to display the List All list filter. This screen summarizes important patient details including treatment and procedure dates. When entering data, Summary serves as a useful reference or as an overview of the patient. All users can view any physician’s narrative for a patient; however, only physicians can update or modify their own narrative. The rest of this form (HPI, Nomogram Scores, Medications, Allergies, and Comorbidities) contains summary fields, which are read-only. To update any of the information in these fields, you must go the related detail form and make changes. You can navigate to the related detail form by either clicking on an item in the DVV list (on the left) or the navigation menus.

Narratives

Only physicians have access to add or change their narratives. When a physician selects a patient and clicks on the Patient Summary button, the summary page is displayed. To add a narrative, click the New button and add your text to the Narrative text area. If a narrative is already present, click the Edit button to make your changes. When you are finished, click the Save button to save your changes.

Patients -> Demographics

Patient demographic information including name, address, phone numbers, dates of birth and death, ethnicity, race, language, and emergency contact information is displayed when Demographics is selected. The DVV list displays the List All list. Demographics is updated regularly by institution systems, but can be entered manually as needed. The patient’s Contact Status is entered and modified using this form.

Patients -> Actions

This is the form used to document actions taken when managing a patient or their data. The form covers the date of the action, any notes about the action taken, and if the action is or is not pending. Selecting Actions refreshes the DVV list to display the Actions list filter. The Actions filter shows a complete list of the documented actions taken for a given patient.

Patients -> Allergies

This form identifies each of the patient’s allergies and their corresponding response. Selecting Allergies refreshes the DVV list to display the Allergies list filter, which shows a complete list of the patient’s Allergies and their responses.

Patients -> Categories

This form displays the categories a patient has been assigned to within the database and whether it is a public or private category. Selecting Categories refreshes the DVV list to display the Categories list filter. For more information on Categories see the List Management section of this manual.

Patients -> Patient Consent

This form is used to document consents the patient has signed or rescinded. It is currently only used for the consent to participate in the database itself. It includes places for consent to use PHI, consent to contact for future studies as well as details about who gave the consent, who obtained the consent, etc. Consents for participation in clinical trials/protocols are currently recorded on the Protocol form.

Patients -> Comorbidities

This form presents the details of each of a patient’s comorbidities. Such as the date it was first identified and the organ system it affects. Selecting Comorbidities refreshes the DVV list to display the Comorbidities list filter.

Patients -> Dietary Intake

This form is for recording the amount of liquid and solid intake of a patient. Selecting Dietary Intake refreshes the DVV list to display the Dietary Intake list filter.

Subform

• Intake Items: Details about specific liquids may be entered here.

Patients -> Family Members

This form will tell you the details about the patient’s family history of cancer; particularly what family member had what type of cancer. Selecting Family Members refreshes the DVV list to display the Family History list filter.

Patients -> Identifiers

This form is used to document various identifiers used to track a patient within the database. The form lists the type of identifier used and the specific value used. Selecting Identifiers refreshes the DVV list to display the Identifiers list filter.

Patients -> Physicians

This form shows a list of every doctor entered in the database that is associated with a patient with detailed contact information. Selecting Physicians refreshes the DVV list to display the Physicians list filter. The DVV list shows a complete list of the physicians caring for a given patient. Clicking on a physician in the list will display his or her details in the form.

Patients -> Protocols

This form provides details about protocols in which a patient is registered or being considered. Information includes the protocol title and related notes, as well as information about the Protocol itself. Selecting Protocols refreshes the DVV list to display all protocols assigned to this patient and loads the Protocols form into the Details section of the Patient Data section. The DVV list shows a complete list of Protocols the patient is or has ever been registered to. Clicking on an item in the list will display its details in the form.

Fields available when editing a Protocol

Adding and Editing Protocols

The Protocols form has buttons related to Protocol information. You may add a new protocol in Add/Edit a New Protocol from the Common Tasks menu and view or edit information for an existing protocol.

Fields available when adding a Protocol

Protocol Status Subform

This form contains details about a specific protocol in which the patient is registered, including information about consent date, treatment date, end of study date, or any other event that has been recorded in the database relating to a specific a protocol.

Patients -> Social Histories

This form provides details about the social history of the patient including occupation, tobacco and alcohol usage, carcinogen exposure, marital status, and family status.

Encounters Drop List

Encounters -> Encounters

Clinical encounters may be recorded using this set of forms. The Encounter form is used to record the type of visit, provider, and vital status. There are four SubForms where detail can be entered for the specific type of encounter: Physical Exams, Rectal Exams, Bimanual Exams, and Review of Systems. To get to these detail forms, click SubForms in the upper left corner of the Encounters form. When an Encounter has a populated detail form, the SubForms link will show a "half-full" icon. When you click SubForms, a list will be displayed with numbers indicating the number of each of the detail forms that have been completed. The DVV list groups the SubForm entries below their related Encounter listing.

Link to blank SubForms	Blank SubForms list	Link to Populated SubForms	Populated SubForms list

Physical Exams SubForm

Details about the physical exam are stored in this sub form.

Rectal Exam SubForm

This subform shows the detailed information for each rectal exam performed on a given patient. The rectal exam findings are recorded in a chart that includes the location of the nodule, likelihood of cancer, or extension.

Bimanual Exam SubForm

Details about any bimanual exams for a patient may be recorded in this section including specific items about the size and location of findings.

Review of Systems SubForm

Results from the review of systems may be recorded in this form

Encounters -> Clinical Stages

This form provides details about the clinical stage of a patient’s disease at different points in time. A staging wizard assists users with choosing the proper stage information. Selecting this button refreshes the DVV list to display the Clinical Stages list filter.

Encounters -> Surveys

This form is used to document surveys completed by a patient. Selecting Surveys refreshes the DVV list to display a complete list of the surveys a patient has completed. The Surveys form lists the type of survey and the specific score as well as the date, survey name, and overall score (if appropriate) for the patient. Typical surveys included in Caisis score continence and potency such as the IIEF and IPSS. Information on specific survey items is listed in a chart with a line for each question and its corresponding results.

Adding New Surveys

The survey and survey items sections have been designed so new surveys can be added. To add a new survey, you must first create a new survey type in the look up codes and then use that same information to create each survey item in the lookup codes table. For example: if you enter a type of New Questions then each survey item should have a look up field name of "SurveyItem_NewQuestions". As long as the survey item is prefixed with "SurveyItem_" and the name of the survey type with no spaces, then the application will associate that information in the Patient Data section. Entering lookup codes will be covered in the Admin section of this document.

Procedures Drop List

Procedures -> Surgeries

This form provides information about surgeries performed on a patient. It includes information that would apply to all surgeries such as: surgeon, institution, and length of stay in hospital, as well as: blood loss, type of anesthesia, etc.

The Surgeries Subforms

Further details of specific types of surgeries are found in the SubForms. To get to these detail forms, click SubForms in the upper left corner of the Surgeries form. When a Surgery has a populated detail form, the SubForms link will show a "half-full" icon. When you click SubForms, a list will be displayed with numbers indicating the number of each of the detail forms that have been completed. The DVV list groups the SubForm entries below their related Surgery listing. Many of the forms below are not accessible until a surgery record is entered. Once the surgery details are saved, the links to the forms below become active and all surgeries entered are visible in the DVV list under the original surgery record.

Procedures can also be associated to a surgery by selecting the date of the surgery from the During Surgery On: select box, see the image below.

Link to blank SubForms	Blank SubForms list	Link to Populated SubForms	Populated SubForms list

Prostatectomy Op SubForm

Details about the Prostatectomy operative procedure are recorded here. Operation Exams related to the Prostatectomy can be entered on a SubForm. Clicking SubForms in the upper left corner of the screen displays the link to the Operation Exams form.

Link to Prostatectomy Pathology SubForms	Prostatectomy Pathology - SubForms