$TXT Created by MCNEILE,KEN at DEV.DEV.FO-HINES.DOMAIN.EXT (KIDS) on Friday, 07/12/13 at 12:49 ============================================================================= Run Date: JAN 17, 2014 Designation: MD*1*32 Package : MD - CLINICAL PROCEDURES Priority: Mandatory Version : 1 SEQ #23 Status: Released Compliance Date: FEB 17, 2014 ============================================================================= Associated patches: (v)MD*1*33 <<= must be installed BEFORE `MD*1*32' Subject: CLINICAL PROCEDURES TERMINOLOGY FILE UPDATES Category: - Routine - Other Description: ============ This patch will correct the following 3 issues: 1) The Clinical Procedures (CP) Terminology TERM file (#704.101) contains terms used during data entry/display in CP Flowsheet. The Office of Informatics and Analytics - Applied Informatics Services (AIS) Terminology Review Group submitted a spreadsheet requesting additions or updates of 90 Terms. 2) A CP Flowsheets Term has a typo in the word Strength 3) The AIS Terminology Review Group has requested an additional Term as a warning message that Vitals are not always in chronological order. ASSOCIATED REMEDY TICKETS: ========================== 1) INC0000000750616 Approved CP Terminology 2) INC0000000815555 Clinical Procedures - Flowsheets: 3) INC0000000756527 CP Flowsheets: Vitals Not Displayed in Chronologic Sequence. ASSOCIATED NSR(S): ================== N/A PARTICIPATING TEST SITES: ========================= Heartland - East HCS (Marion) Huntington VA Medical Center North Texas HCS (Dallas) REMEDY OVERVIEW: ================ 1) INC0000000750616 Approved CP Terminology Problem: -------- The Clinical Procedures (CP) Terminology TERM file (#704.101) contains terms used during data entry/display in CP Flowsheet. The Office of Informatics and Analytics - Applied Informatics Services (AIS) Terminology Review Group submitted a spreadsheet requesting additions or updates of 90 Terms. The following list documents the approved changes. Additions: ---------- Anesthesia planned ASA Physical Status Barriers to Learning Chief Concern/Complaint Dentures Drain Suction cm H20 Drain Suction Type ENTERAL NUTRITION DELIVERY METHOD ENTERAL NUTRITION LINE TRACED ENTERAL NUTRITION SYSTEM MAINTENANCE ENTERAL NUTRITION TUBE PLACEMENT VERIFIED ENTERAL TUBE ASPIRATE COLOR ENTERAL TUBE SITE CONDITION CHECKED Epidural: Bolus (ml) Epidural: Continuous Rate (ml/hr) Epidural: Dermatome Sensory Level - Left Epidural: Dermatome Sensory Level - Right Epidural: Side Effects Handoff Report Insulin Pump SQ Infusion On? Intake - CBI Irrigation to Subtract (negative number) INTAKE - ENTERAL TUBE FLUSH Labs per orders Mallampati Score Med Last Dose: Antibiotic Med Last Dose: Anticoagulant Med Last Dose: Aspirin Med Last Dose: Non-steroidal Anti-inflammatory Drug Moderate Sedation: PreAssess: Previous Mod Sed. Complications Moderate Sedation: PreAssess: Substance Abuse Moderate sedation: Pre-assessment appliances removed Moderate sedation: Pre-assessment CPRS Health HX Reviewed Moderate sedation: Pre-assessment Time out Moderate Sedation: Preparation Moderate sedation: Time Out: Patient Identifiers Monitor Placed Output - CBI Drainage PACU - Time of reversal agent Patient Education provided prior to sedation PCA - Continuous mcg/hr (Basal) PCA - Continuous mg/hr (Basal) PCA - Level of Consciousness PCA - Side Effects PCA - Total mcg per Shift PCA - Total mg per Shift Preprocedure: 12 lead EKG done? Preprocedure: Allergies reassessed and documented Preprocedure: Antibiotic given? Preprocedure: Antibiotic ordered? Preprocedure: Blood Transfusion consent current? Preprocedure: Chest Xray done? Preprocedure: Dentures removed? Preprocedure: Disposition of Clothing Preprocedure: Disposition of Valuables Preprocedure: Driver/Escort to home confirmed Preprocedure: Fingerstick Glucose done? Preprocedure: Glasses / Contacts removed? Preprocedure: H and P current? Preprocedure: Hearing Aids in place? Preprocedure: Home Medications taken/time Preprocedure: Hospital Gown on? Preprocedure: Informed Consent current Preprocedure: Jewelry Removed? Preprocedure: Labs done? Preprocedure: NPO since (date/time) Preprocedure: Planned Procedure Preprocedure: Premedication administered? Preprocedure: Premedication ordered? Preprocedure: Procedure site marked correctly Preprocedure: Prosthetics/Implants? Preprocedure: Type and Cross Match done? Preprocedure: Type and Screen done? Preprocedure: Vitals Signs done? Preprocedure: Voided? Procedure Location Procedure Time Procedure, planned Time Out: Patient Identification Method Time Out: Verbal confirmation by team of procedure and laterality Time Out: Verbal confirmation by team of procedure to be performed Updates: -------- Behavior Cardiac Ectopy Cardiac Rhythm Education Topic Enteral Nutrition Type PACU - Discharge Critieria Urine Characteristics Weight Weight At Admission Weight Dry Resolution: ----------- Post-Init routine MDTERMX will make the above Additions/Updates to the CP Terminology TERM File (#704.101) and TERM_TYPE file (#704.102) as described in the Problem Section above. The details of each of these terms is in the Clinical Observation (CliO) Terminology Dictionary And Clinical Data Model Documentation that is listed below. 2) INC0000000815555 Clinical Procedures - Flowsheets: Problem: -------- The Clinical Procedures (CP) Terminology TERM file (#704.101) has the word Strength misspelled in the term "LOWER LIMB EXTREMITIES STRENTGH". Resolution: ----------- Post-Init routine MDTERMX will make a spelling correction in the Clinical Procedures TERM file (#704.101) for the word STRENGTH in the term "LOWER LIMB EXTREMITIES STRENGTH". 3) INC0000000756527 CP Flowsheets: Vitals Not Displayed in Chronologic Sequence. PSPO: ----- PSPO #2328 Problem: -------- Vitals data when accumulated from multiple sources (currently Vitals package and CP Flowsheets) are not displayed in chronological order in CP Flowsheets. The AIS Terminology Group has requested an additional Term be added to serve as a column header type of warning message. Resolution: ----------- Post-Init routine MDTERMX will make the Addition to the CP Terminology TERM File (#704.101) and TERM_TYPE file (#704.102) for the following string: "Caution-Vitals may not display in correct sequence. Review times carefully" DOCUMENTATION: ============== Documentation is available for the Clinical Observation (CliO) Terminology Dictionary And Clinical Data Model Documentation on the ANONYMOUS.SOFTWARE directory at one of the following Office of Information (OI) Field Offices. Sites will be able to download the documentation in the ".PDF" format. The preferred method is to FTP the files from: Download.vista.domain.ext This transmits files from the first available FTP server. Sites may also elect to retrieve documentation directly from a specific server as follows: Albany ftp.fo-albany.domain.ext Hines ftp.fo-hines.domain.ext Salt Lake City ftp.fo-slc.domain.ext File Name: Description: Protocol: ========== ============ ========= MD1_0P32TERM.PDF CliO Terminology Dictionary Binary And Clinical Data Model Documentation may be found on the System Design and Development Web page at: http://www.domain.ext/vdl INSTALLATION INSTRUCTIONS: ========================== If installed during the normal workday, it is recommended that the Clinical Procedures users be off the system. Other VISTA users will not be affected. Install Time - less than 5 minutes (unless otherwise indicated) 1. Load Transport Global --------------------- Choose the PackMan message containing this patch and invoke the INSTALL/CHECK MESSAGE PackMan option. 2. Start Up KIDS ------------- Start up the Kernel Installation and Distribution System Menu [XPD MAIN]: Edits and Distribution ... Utilities ... Installation ... Select Kernel Installation & Distribution System Option: INStallation --- Load a Distribution Print Transport Global Compare Transport Global to Current System Verify Checksums in Transport Global Install Package(s) Restart Install of Package(s) Unload a Distribution Backup a Transport Global 3. Select Installation Option: --------------------------- NOTE: The following are OPTIONAL - (When prompted for the INSTALL NAME, enter MD*1.0*32): a. Backup a Transport Global - This option will create a backup message of any routines exported with this patch. It will not backup any other changes such as DD's or templates. b. Compare Transport Global to Current System - This option will allow you to view all changes that will be made when this patch is installed. It compares all components of this patch (routines, DD's, templates, etc.). c. Verify Checksums in Transport Global - This option will allow you to ensure the integrity of the routines that are in the transport global. 4. Select Installation Option: Install Package(s) --------------------------------------------------- **This is the step to start the installation of this KIDS patch: a. Choose the Install Package(s) option to start the patch install. b. When prompted 'Want KIDS to INHIBIT LOGONs during the install? NO//' answer NO c. When prompted 'Want to DISABLE Scheduled Options, Menu Options, and Protocols? NO//' answer NO NOTE: Post-Init routine MDTERMX will be automatically deleted after it has made the file modifications. Routine Information: ==================== The second line of each of these routines now looks like: ;;1.0;CLINICAL PROCEDURES;**[Patch List]**;Aug 2, 2012;Build 7 The checksums below are new checksums, and can be checked with CHECK1^XTSUMBLD. Routine Name: MDTERMX Before: B4314808 After: B4314808 **32** ============================================================================= User Information: Entered By : MCNEILE,KEN Date Entered : SEP 21, 2012 Completed By: SHERMAN,BILL Date Completed: JAN 15, 2014 Released By : COWNIE,KEVIN Date Released : JAN 17, 2014 ============================================================================= Packman Mail Message: ===================== $END TXT