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.)
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.)
- 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.
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).