{"id":6042,"date":"2023-03-20T16:14:24","date_gmt":"2023-03-20T16:14:24","guid":{"rendered":"https:\/\/edren.org\/ren\/?page_id=6042"},"modified":"2024-05-22T08:21:17","modified_gmt":"2024-05-22T08:21:17","slug":"vital-data","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/unithdbk\/vital-data\/","title":{"rendered":"Vital Data"},"content":{"rendered":"<p>This page is only useful to health professionals working in the Edinburgh Renal Unit.<\/p>\n<p>We use Vital Data as the electronic patient record.\u00a0 This is used to deliver clinical care and also for audit \/ governance \/ quality improvement.\u00a0\u00a0On these pages, we give some notes on how to keep this record up to date.\u00a0 (See also the <a href=\"https:\/\/scottish.sharepoint.com\/sites\/TransplantAndRenalData\">Transplant And Renal Data Zone<\/a> for some VitalData FAQs.)<\/p>\n<p>&nbsp;<\/p>\n<h1>Working with VitalData<\/h1>\n<h3>Updates in mid-2024 when our &#8220;LEAP server&#8221; was retired<\/h3>\n<p>We are moving to new ways of generating the ward list, inpatient dialysis prescriptions, medicines reconciliation forms and the reciprocal Cr plot etc.\u00a0 For a quick &#8220;how to&#8221; guide on working with the new ward lists, see here: <a href=\"https:\/\/edren.org\/ren\/wp-content\/uploads\/2024\/05\/WardList_QuickRefGuide.pdf\">Ward List Quick Reference Guide<\/a>.<\/p>\n<p>&nbsp;<\/p>\n<h3>Aide memoirs<\/h3>\n<p>Click link for a really helpful set of <a href=\"https:\/\/edren.org\/ren\/wp-content\/uploads\/2023\/08\/VitalData-Checklists.pdf\">VitalData Checklists<\/a> compiled by Ailish Nimmo, Hannah Preston and Oliver Thomas (renal SpRs).<\/p>\n<p>&nbsp;<\/p>\n<h3>Problem list<\/h3>\n<p>Should be updated in real time.\u00a0 Review at each clinic appointment.\u00a0 Keep relevant by discontinuing historic problems (by setting a finish date).<\/p>\n<p>Times at which problem list (and indeed other fields) should be updated:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>discharge from hospital<\/li>\n<li>major events (e.g. amputations)<\/li>\n<li>change in RRT modality<\/li>\n<\/ul>\n<p><em>(NB There would be the option to use the &#8220;Diagnoses&#8221; tab to record Read-coded diagnoses.\u00a0 We have not chosen to do this routinely.)<\/em><\/p>\n<p>&nbsp;<\/p>\n<h3>Correspondence<\/h3>\n<ul style=\"list-style-type: disc;\">\n<li>letters<\/li>\n<li><span style=\"font-family: 'Source Sans Pro';\">patient review &gt; <span style=\"text-decoration: underline;\"><strong>clinical history<\/strong><\/span>: for clinical reviews (e.g. monthly dialysis reviews), telephone calls, e-mails etc.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3>RRT planning tab<\/h3>\n<p>A useful aide-memoire for patients approaching ESKD.\u00a0 Can &#8220;activate&#8221; the screen by entering a new entry with today&#8217;s date (click &#8220;+&#8221;).<\/p>\n<p>(Remember that it is the <strong><span style=\"text-decoration: underline;\">Patient Renal History<\/span><\/strong> screen that sets the overall status of the patient and is used for registry returns &#8211; see below.\u00a0 So remember to update this screen also when entering data on RRT planning.)<\/p>\n<p>&nbsp;<\/p>\n<h3>Transplant review tab<\/h3>\n<p>Main place to record significant events in transplant recipients clinic, procedures, DSA results, rejection events, stent removal etc.).\u00a0 The advantage of recording these events as coded diagnoses is that this makes audit \/ QIP much easier.<\/p>\n<p>&nbsp;<\/p>\n<h3>Essential data that are sometimes neglected!<\/h3>\n<ul style=\"list-style-type: disc;\">\n<li>Patient Review &gt; <span style=\"text-decoration: underline;\"><strong>PRD<\/strong><\/span> &#8211; can find list of diagnoses on <a href=\"https:\/\/www.srr.scot.nhs.uk\/Projects\/Methods.html\">SRR website<\/a><\/li>\n<li>Patient Review &gt; <span style=\"text-decoration: underline;\"><strong>Patient Renal History<\/strong><\/span> &#8211; 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.).<\/li>\n<li>Administration &gt; Contacts &gt; <span style=\"text-decoration: underline;\"><strong>Primary consultant<\/strong><\/span><\/li>\n<li>Patient Review &gt; <span style=\"text-decoration: underline;\"><strong>Mortality<\/strong><\/span> &#8211; EDTA code is bare minimum to record<\/li>\n<\/ul>\n<p><em>NB These fields are all important for recording information that is returned to the Scottish Renal Registry.<\/em><\/p>\n<p>&nbsp;<\/p>\n<h3>Adding patients<\/h3>\n<p>On a desktop computer (not WYSE): select person &gt; check (by CHI) that patient is not already registered on VD by clicking &#8220;Fetch&#8221;.\u00a0 If not present then can then add by clicking &#8220;New&#8221; (and then select the correct health board &#8211; if more than one option appears then select the one that is appropriate for the current address).<\/p>\n<p>&nbsp;<\/p>\n<h1>Recording data for the biopsy registry return<\/h1>\n<p>We collect and return data to PHS as part of the Scottish Renal Biopsy Registry.<\/p>\n<p>The data that we need to be enter manually are:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Indication:\n<ul style=\"list-style-type: disc;\">\n<li>Indication 1 = main indication for the biopsy (from drop-down list)<\/li>\n<li>Indication 2 (optional) = any secondary indication from drop-down list<\/li>\n<li>Indication 3 (optional) = from drop-down list<\/li>\n<li>Indication 4 (optional) = free-text<\/li>\n<li>Elective or urgent = usually inpatient is urgent and day-case is elective<\/li>\n<li>Day-case or inpatient = self-explanatory<\/li>\n<\/ul>\n<\/li>\n<li>Diagnosis:\n<ul style=\"list-style-type: disc;\">\n<li>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.)<\/li>\n<li>Biopsy adequate (coded) = as above (but with slightly different codeset for some reason)<\/li>\n<li>Number of glomeruli = total number of glomeruli in the formalin-fixed tissue<\/li>\n<li>Main diagnosis = main diagnosis in this biopsy (selected from drop-down list)<\/li>\n<li>Secondary diagnosis (optional) = any secondary diagnosis (from drop-down list)<\/li>\n<li>Comments 1 &amp; 2 (optional) = free-text comment on diagnosis<\/li>\n<\/ul>\n<\/li>\n<li>Complications:\n<ul style=\"list-style-type: disc;\">\n<li>Major complication = major complications within 30 days (yes or no)<\/li>\n<li>Major complication (coded) = from drop-down list<\/li>\n<li>Complication details (optional) = free-text comment on complications<\/li>\n<li>First biopsy for this diagnosis = yes or no &#8211; was this the first biopsy giving this diagnosis<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>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).<\/p>\n<p>All other data fields are retrieved automatically from VitalData.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>This page is only useful to health professionals working in the Edinburgh Renal Unit. We use Vital Data as the electronic patient record.\u00a0 This is used to deliver clinical care and also for audit \/ governance \/ quality improvement.\u00a0\u00a0On these pages, we give some notes on how to keep this\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/unithdbk\/vital-data\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":6,"featured_media":0,"parent":19,"menu_order":229,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"class_list":["post-6042","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/6042","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=6042"}],"version-history":[{"count":17,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/6042\/revisions"}],"predecessor-version":[{"id":6400,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/6042\/revisions\/6400"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/19"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=6042"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}