Neuro Tracker | Consult Form | Patient Info | Progress Note | Graphs & Reports
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In 2007 I began a project with the Neurotrauma center at San Francisco General Hospital and BASIC ( Brain & Spinal Injury Center) to create a DBMS (Data Based Management System) to track TBI (Traumatic Brain Injury) patients for purposes of treatment and research.
Over the last seven years we have created an elaborate and sophisticated system that replaced the 3 home brewed databases and several excel sheets that were being used for previous tracking.
The system employs three systems:
- Patient Info: to track each hospital visit stay and the info associated with a patient across multiple visits
- Consult Form: A series of forms employed for the initial consult/entry into the system
- Progress Notes: a set of daily progress forms tracking and assessing the TBI patients in ICU (Intensive Care Unit) and on the Floor
Neurotracker™ is an integrated Filemaker-based management system to track details and measurements which goes far beyond the Hospital forms to enhance treatment for the patients and enable study and analysis to better improve current and future patient care.
Features of the overall system (details of the 3 main systems explained below)
- There is a many-to-one relationship used for patients. Each patient has a unique MRN (Medical Record Number) and a unique Visit ID number so that One visit equals one record and a patient can be tracked across multiple visits
- A Consult form is created at the same time as a new Patient Record. If there is a previous visit/record old info is rolled over to the new record for verification and updating, preserving old info for comparison
- A PDF printout summary of the Consult is created and uploaded to the hospital system for reference as well as a billing record so that the consult can be submitted to the billing department
- Some information is imported into the Patient record ( Insurance Info) via an ODBC connection to the SFGH Hospital system
- A Progress Note is created for that day and for the next day’s rounds. Data from the consult is rolled into the next day’s Progress note to aid entry. As a progress note is completed and electronically signed, a new progress note is created for the next day with selected data rolled into the new record until the patient is discharged
- Selected elements in the progress note are flagged for the billing department
- entry is performed on Laptops, iPads and on desktop computers
- Progress notes summaries are printed to paper and PDFs for inclusion in the patient’s physical and electronic records. For many elements only THAT day’s events are recorded so as to better track a day’s treatment. A history of a patients Progress forms can easily be pulled up and Reviewed on-screen
- Upon discharge, a well formatted Summary of all data is created and saved to PDF for inclusion with the patient’s records.