Sample Kidney Data Entry Guide

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Contents

Introduction

This guide was made in order to help new and current RSAs efficiently and precisely enter kidney 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 kidney patient data as well. In the event kidney 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 kidney 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 hosptial documentation including dictated initial consults, clinic forms, diagnostic and pathology reports.
  • RR – Data reviewed for research by the Attending Pathologist(Only for Kidneypathology 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 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. 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.


Biochemical Marker / Lab Tests

Under the Diagnostics tab click on Lab Tests. All lab tests done at the hospital are automatically entered into Caisis. If the lab tests are done outside you will need to be enter them from either the clinic forms or outside reports in the "OutsideCorres" folder in EMR. Lab tests you will need to enter are "CR", and "BUN".

Always enter the Date, Lab Test, Result, Data Source, and Data Quality. 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

Always enter Type, Target, Result, Physician (radiologist who interpreted the scan), Data Source, and Data Quality in the main Diagnostic form in Caisis.

Results provided on the clinic form should take precedence over scanned results from EMR. If no scan is recorded on the data form, an entry can be made based on evidence in EMR. This evidence may come from a dictation or a radiology scan performed either here or at an outside institution scanned in EMR. Paste the radiology report impression into the Notes in Caisis. Refer to the four options below when secting the results (Normal, Equivocal, Suspicious for Metastasis, Abnormal Malignant). If there are any doubts as to which of the four options to enter, enter Unknown as the result. Under the Kidney Findings sub-form enter the sites for any Equivocal, Suspicious, or Abnormal Malignant findings with as much detail from the scan as possible. If it is not in the scan, it should not be recorded. If you feel at any time that you are interpreting the scan, enter the result as Unknown. As a data entry RSA you are not interpreting scans but merely recording a physician’s interpretation.

Primary Lesion: For any lesion directly involving either kidney.
1. "Abnormal Malignant" - for a solid enhancing lesion
2. "Equivocal"
a) Complex Cystic Lesion
b) Solid lesion with questionable enhancement
3. "Abnormal Non-malignant"
a) Simple Cyst
b) Abscess
c) Surgical Complication
d) Nephrolithiasis
e) Atrophic Kidney
f) Hydronephrosis
g) No Diagnostic Findings
h) Post surgical kidney (either post-partial, or post-radical)
4. "Unknown" - for all occasions where it is unclear
All other sites (including renal bed/ renal fossa):
1. "Abnormal Malignant"
a)Attending review on data form states that a radiologic exam showed metastatic disease (or local recurrence)
b)Radiologist explicitly states this is metastatic disease
2. "Suspicious for Metastasis"
a)Radiologist or physician states that this is likely metastatic disease
3. "Equivocal"
a)Malignancy cannot be excluded
b)Likely not metastatic disease but differential diagnosis includes RCC
4. "Abnormal Non-malignant"
a)All others

Biopsies

To completely enter a biospy you need to enter a procedure record, a pathology record using the outside institution's findings, and a pathology record using the hospital'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 biopsies done outside even if they have been reviewed and are avaialable in EMR.

Pathology Record(s)

Surveys

Encounters

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

Always enter an Encounter record with the Date, Type of visit, Chief Complaint (ie. Kidney Cancer), Physician, Data Source and Data Quality for every data form or dictated visit you enter into Caisis.

Clinical Stage

Under the Encounters tab click on Clinical Stage.

Disease State

Under the Outcomes tab click on Status. Always include the Date, Disease, Status, Data Source and Data Quality along with the Status.

To determine the Disease check the patients' surgical and pathological history in the HPI section of the Caisis form. If it is a kidney patient then you will need to check the Nephrectomy's histology in the Pathology section in Caisis.

Select "Renal Cell Carcinoma" for Disease if the hitology field is:
  • Conventional Clear Cell
  • Chromophobe
  • Papillary
  • Collecting Duct
  • Unclassified
Select "Kidney" for Disease if the hitology field is:
  • Necrosis
  • Angiomyolipoma (AML)
  • Oncocytoma
  • Benign
  • VHL
  • Decreased renal function
  • Wilm’s
The following are different Status types you can select:
  • Stable – Alive (Use if a status is not provided on the form.)
  • NED – No Evidence of Disease
  • AWD – Alive with Disease
  • BCR – Biochemical Recurrence
  • LCR – Local Recurrence
  • Mets – Distant Metastasis

Kidney 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(ie. Nephrectomy).
  • 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

Nephrectomy

  • Date
  • Procedure
  • Site
  • Institution
  • Surgeon
  • Surgeon Type
  • Data Source
  • Data Quality

Nephrectomy Details

Pathology

a) From Operation On

b) Source Procedure

c) Path Report Date

d) Path #

e) Specimen Type

f) Institution

g) Histology

h) Secondary Histology

i) Pathologist

j) Data Source

k) Data Quality(RR if Path report is done by the Attending Pathologist)

Nephrectomy Pathology

Pathology Stages

a) Disease

b) Staging System - "UICC_02"

c) T Stage

Regional Lymph Node Dissection (PLND)

RLND Pathology

Pathology Node Findings

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