This page is only useful to health professionals working in the Edinburgh Renal Unit.

We use Vital Data as the electronic patient record.  This is used to deliver clinical care and also for audit / governance / quality improvement.  On these pages, we give some notes on how to keep this record up to date.  (See also the Transplant And Renal Data Zone for some VitalData FAQs.)

 

Working with VitalData

Aide memoirs

Click link for a really helpful set of VitalData Checklists compiled by Ailish Nimmo, Hannah Preston and Oliver Thomas (renal SpRs).

 

Problem list

Should be updated in real time.  Review at each clinic appointment.  Keep relevant by discontinuing historic problems (by setting a finish date).

Times at which problem list (and indeed other fields) should be updated:

• discharge from hospital
• major events (e.g. amputations)
• change in RRT modality

(NB There would be the option to use the “Diagnoses” tab to record Read-coded diagnoses.  We have not chosen to do this routinely.)

 

Correspondence

• letters
• patient review > clinical history: for clinical reviews (e.g. monthly dialysis reviews), telephone calls, e-mails etc.

 

RRT planning tab

A useful aide-memoire for patients approaching ESKD.  Can “activate” the screen by entering a new entry with today’s date (click “+”).

(Remember that it is the Patient Renal History screen that sets the overall status of the patient and is used for registry returns – see below.  So remember to update this screen also when entering data on RRT planning.)

 

Transplant review tab

Main place to record significant events in transplant recipients clinic, procedures, DSA results, rejection events, stent removal etc.).  The advantage of recording these events as coded diagnoses is that this makes audit / QIP much easier.

 

Essential data that are sometimes neglected!

• Patient Review > PRD – can find list of diagnoses on SRR website
• Patient Review > Patient Renal History – in particular we have been historically poor at recording acute RRT and recovery from this; it is this screen that sets the overall status of the patient (i.e. pre-RRT, conservative, HD, PD, Tx etc.).
• Administration > Contacts > Primary consultant
• Patient Review > Mortality – EDTA code is bare minimum to record

NB These fields are all important for recording information that is returned to the Scottish Renal Registry.

 

Adding patients

On a desktop computer (not WYSE): select person > check (by CHI) that patient is not already registered on VD by clicking “Fetch”.  If not present then can then add by clicking “New” (and then select the correct health board – if more than one option appears then select the one that is appropriate for the current address).

 

Recording data for the biopsy registry return

We collect and return data to PHS as part of the Scottish Renal Biopsy Registry.

The data that we need to be enter manually are:

• Indication:
  • Indication 1 = main indication for the biopsy (from drop-down list)
  • Indication 2 (optional) = any secondary indication from drop-down list
  • Indication 3 (optional) = from drop-down list
  • Indication 4 (optional) = free-text
  • Elective or urgent = usually inpatient is urgent and day-case is elective
  • Day-case or inpatient = self-explanatory
• Diagnosis:
  • Biopsy adequate = defined as whether or not the result gave enough information to make a diagnosis or clinical decision (rather than any definition based on number of glomeruli etc.)
  • Biopsy adequate (coded) = as above (but with slightly different codeset for some reason)
  • Number of glomeruli = total number of glomeruli in the formalin-fixed tissue
  • Main diagnosis = main diagnosis in this biopsy (selected from drop-down list)
  • Secondary diagnosis (optional) = any secondary diagnosis (from drop-down list)
  • Comments 1 & 2 (optional) = free-text comment on diagnosis
• Complications:
  • Major complication = major complications within 30 days (yes or no)
  • Major complication (coded) = from drop-down list
  • Complication details (optional) = free-text comment on complications
  • First biopsy for this diagnosis = yes or no – was this the first biopsy giving this diagnosis

 

These data are ideally completed by the nephrologist who requested the biopsy (as sometimes the indication and diagnosis are not immediately obvious from casenote review).

All other data fields are retrieved automatically from VitalData.