Cortex gold audit report decoder
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Cortex GOLD Audit Report Decoder. Heather Sousa Cortex User Group 2011 New Orleans. Reasons to Audit. To Track who entered or deleted information on a Case or a Patient. To track what information was entered or deleted on a Case or Patient. CAP Lab General Checklist question:

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Cortex GOLD Audit Report Decoder

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Cortex gold audit report decoder

Cortex GOLDAudit Report Decoder

Heather Sousa

Cortex User Group

2011

New Orleans


Reasons to audit

Reasons to Audit

  • To Track who entered or deleted information on a Case or a Patient.

  • To track what information was entered or deleted on a Case or Patient.

  • CAP Lab General Checklist question:

    • GEN.43800 Data Input ID


Cap laboratory general checklist compliance

CAP; Laboratory General Checklist Compliance

GEN.43800Data Input IDPhase II

There is an adequate system to identify all individuals who have entered and/or modified patient data or control files.

NOTE: When individual tests from a single test order (e.g. multiple tests with same accession number) are performed by separate individuals and the test result is entered into the LIS, the system must provide an audit trail to document each person involved. For example, a single accession number having orders for electrolytes and a lipid panel may have testing done by two or more individuals. The laboratory should be able to identify the responsible personnel who performed each test and posted the data. This includes sequential corrections made to a single test result. If autoverification is used, then the audit trail should reflect that the result was verified automatically at a given time.

With point-of-care testing, if the individual performing the test is different than the individual entering test data into the LIS, both should be uniquely identified by the system and retrievable by audit trail.

REFERENCES

1) Jones JB. The importance of integrating POCT data into an organized database. Advance/Laboratory. 1999;8(9):8-10 2) Halpern NA, Brentjens T. Point of care testing informatics. The critical care-hospital interface. Crit Care Med. 1999;15:577-591


Gold 2009 7 archive reports

Gold 20097 Archive Reports

  • With Gold 2008 SP1 all Gold Users have AutoAudits set up in their system.

  • Gold versions prior to this must have the AutoAudit scripts installed and running for these reports to produce results.

  • The Audit_Archive_Reports are used if you have too much data audited, and want to store/archive it in these reports. This way when you run Audit_Report it won’t take so long, because you’ve archived, for example, all cases except the past 3 years.


Audit report by accession number

AUDIT_REPORTby Accession Number

Tables Audited by this Report

Cases Case_Screener Case_Diagnosis Case_SpecialStatus Case_Procedure PrintJob

Note: Even though you have a choice for Accession Range, Audit will use the “From” Accession number only.


Audit report by action type by accession number

AUDIT_REPORT_BY_ACTION_TYPEby Accession Number

ACTION TYPE = Delete, Insert, View, Update

Tables Audited by this Report

Cases Case_Screener Case_Diagnosis Case_SpecialStatus Case_Procedure PrintJob

Note: You should only Audit one Accession number at a time, even though you get the choice to enter a range of Accession numbers.


Audit report for patient by patient number or patient name

AUDIT_REPORT_FOR_PATIENTby Patient Number or Patient Name

Tables Audited by this Report

PatientPayorPatient

Enter Patient’s last name and choose from a list

OR

Enter the Patient Number

You may use this report to see who changed a Patient’s name or Insurance Information


Audit report for patient by action type by patient number or patient name

AUDIT_REPORT_FOR_PATIENT_BY_ACTION_TYPEby Patient Number or Patient Name

ACTION TYPE = Delete, Insert, View, Update

Tables Audited by this Report

PatientPayorPatient

Enter Patient’s last name and choose from a list

OR

Enter the Patient Number

You may use this report to see who changed a Patient’s name or Insurance Information


Cases caseid

Cases.CaseID

Hover over the Accession number on the case to get the CaseID


Cases clinicianid

Cases.ClinicianID

  • Clinician ID: See number to the right of the Clinician Name in Maintain Clinicians area.


Cases clinlocationid

Cases.ClinLocationID

Clinician Location ID: See the number to the Right of the Location.

In Maintain Clinician Locations area.


Cases statuscode

Cases.StatusCode

The status of the case as it is signed out.

  • 50006Completed/Locked

  • 50008Final Print

  • 50002Gross Entered

  • 50004Gross Printed

  • 50000Open


Cases patientid

Cases.PatientID

Patient ID: Hover with your curser over the Patient Name

Or look at the bottom right corner of Case Management screen


Case diagnosis areacode

Case_Diagnosis.AreaCode

The codes entered for a case are broken down into the Groups below. Each group has a numerical code that is reference in the Audit. Codes are used with Hybrid version of Non Gyns.

  • GYN

    • 40004 Comments

    • 40000 Diagnosis

    • 40002 Hormonal

    • 40001 Inflammation

    • 40005 Maturation Index

    • 40006 Other

    • 40003 Quality

  • NON GYN

    • 45004 Comments

    • 45000 Diagnosis

    • 45003 Quality


Case diagnosis caseid

Case_Diagnosis.CaseID

Hover over the Accession number on the case to get the CaseID


Case diagnosis diagnosiscode

Case_Diagnosis.DiagnosisCode

  • Internal code for each Diagnosis on the case. See your Maintain Diagnosis area for your Lab’s specific codes.


Case diagnosis primaryflag

Case_Diagnosis.PrimaryFlag

Case_Screener.PrimaryFlag = Case_Diagnosis.PrimaryFlag

  • The primary screener is marked “Y”, and all other screeners are marked “N”.

  • Primary Screener = the highest ranked person signing out the case.

    • CYTOLOGY ranking from highest to lowest: Pathologist/QC2/QC1/Cytotechnologist

    • HISTOLOGY ranking from highest to lowest: PathDiagnosis/PathFrozen/PathMicroscopic/PathGross


Case diagnosis screenertype

Case_Diagnosis.ScreenerType

StaffTypeCode and ScreenerType are the same animal.

StaffTypeCode is in the Case_Screener table

ScreenerType is in the Case_Diagnosis table

Cytotechnologist = 1

Pathologist = 2 (for all case types)


Case screener caseid

Case_Screener.CaseID

Hover over the Accession number on the case to get the CaseID


Case screener controlnumber

Case_Screener.ControlNumber

Control number lets you know where you are (which column) in the diagnosis grid, and whether you are in Cytology or Histology.

Cytology control number is always = 1

Histology is Pathologist type dependent: Gross=2, Micro=4, Diagnosis=6, Frozen=8

1

GYN

HISTO

2

4

6

8


Case screener date

Case_Screener.Date

Date the diagnosis was entered into the grid

GYN

HISTO


Case screener primaryflag

Case_Screener.PrimaryFlag

Case_Screener.PrimaryFlag = Case_Diagnosis.PrimaryFlag

  • The primary screener is marked “Y”, and all other screeners are marked “N”.

  • Primary Screener = the highest ranked person signing out the case.

    • CYTOLOGY ranking from highest to lowest: Pathologist/QC2/QC1/Cytotechnologist

    • HISTOLOGY ranking from highest to lowest: PathDiagnosis/PathFrozen/PathMicroscopic/PathGross


Case screener staffid

Case_Screener.StaffID

  • Internal Staff identification code for this screener.

  • Find this in the Maintain Staff area in the Restricted Files


Case screener staffid1

Case_Screener.StaffID

  • Internal Staff identification code for this screener.


Case screener stafftypecode

Case_Screener.StaffTypeCode

StaffTypeCode and ScreenerType are the same animal.

StaffTypeCode is in the Case_Screener table

ScreenerType is in the Case_Diagnosis table

Cytotechnologist = 1

Pathologist = 2 (for all case types)

QC1, Transcriptionist = 3

QC2, Consultant 1 = 4 (see chart for other StaffTypeCodes)


Case specialstatus caseid

Case_SpecialStatus.CaseID

Hover over the Accession number on the case to get the CaseID


Case specialstatus entereddate

Case_SpecialStatus.EnteredDate


Case specialstatus onsetdate

Case_SpecialStatus.OnsetDate


Case specialstatus sequence

Case_SpecialStatus.Sequence

The sequence = which row the Special Status codes were entered into.

1

2


Case specialstatus specialstatuscode

Case_SpecialStatus.SpecialStatusCode


Printjob caseid

PrintJob.CaseID

Hover over the Accession number on the case to get the CaseID


Printjob clinlocationnumber

PrintJob.ClinLocationNumber

Clinician Location ID:

See the number to the Right of the Location. In Maintain Clinician Locations area.


Printjob cliniciannumber

PrintJob.ClinicianNumber

  • Clinician ID: See number to the right of the Clinician Name in Maintain Clinicians area.


Printjob finalprint

PrintJob.FinalPrint

For example: From Case Management, press Print/Fax button

On your Audit

Final print button checked = Y

Final print button not checked = N


Printjob numberofcopies

PrintJob.NumberOfCopies

The audit will pull “Number of Copies” from wherever the print job was sent to. For example, if the case is printed via the default printer then it’s the number of copies associated with this Report Location “default printer”.


Printjob printserverworkstationname

PrintJob.PrintServerWorkStationName

Used to indicate that a job is in processing.  Whenever a Print Server grabs a group of jobs to process, the first thing it does is stamp them with the name of the PrintServer that is processing them.  It does this for single Printserver systems as well as multiple.

Scroll to the right when in print job viewer


Printjob reportlocationname

PrintJob.ReportLocationName

Default Can be set up when you first log into GOLD

Where your patient reports are printing

One-offs Can be chosen when you Print from Case Management (drop down)


Printjob reportlocationdestination

PrintJob.ReportLocationDestination

In Print Job viewer this is “Device/Fax#”. Detailed version of Rpt. Location Name

BizHub 451 is specific Report Printer

Individual Fax number is specific to Fax to Brooks-office


Printjob requestedbystaffnumber

PrintJob.RequestedByStaffNumber

Staff name can be found on Tracking tab on case, but the Audit_Report lists that persons “StaffNumber” found in “Maintain Staff Codes” in Restricted Files area.


Printjob scheduletime

PrintJob.ScheduleTime

The audit shows the Scheduled Time that is in the Print Job Viewer. Therefore it audits the time dependent upon how your lab has this set up.

Scheduled Time can be set up in ClinLocation or at the Designator level


Printjob systemcodesource

PrintJob.SystemCodeSource

Internal Codes audited:

370003ClinLocation

370006 ClinLocation Rule

370004Copies To

370001 Designator

370002 Designator Rule

370009 Interface

370005 One-Off


Printjob systemcodestatus

PrintJob.SystemCodeStatus

Internal Codes Audited:

270005Deleting,270003 Error

270002 Paused,270001 Processing,270004 Ready


Printjob systemcodetype

PrintJob.SystemCodeType

Internal Codes Audited:

230002Default Fax,230001 Default Printer,230004 Fax

230006 Interface,230003 Printer230008 SaveToFile

230005 Secure Delivery System

= Report Location Types


Printjob systemcodeprintfiletype

PrintJob.SystemCodePrintFileType

Internal Codes Audited

440001Adobe PDF

440004 Post Script

440002 Word Doc

440003 Word Docx


Printjob systemcodeprintfileschema

PrintJob.SystemCodePrintFileSchema

Internal Codes Audited

430002AccessionNumber and Clinician and Location

430003Accession Number and Time Stamp

430001Accession Number Only

= Print Naming Schema


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NOTE: Not all laboratories use the extra fields in the Procedures Grid in Gold.


Case procedure authorizationnumber

Case_Procedure.AuthorizationNumber


Case procedure billeddate

Case_Procedure.BilledDate

Go to Procedures and scroll to the right


Case procedure caseid

Case_Procedure.CaseID

Hover over the Accession number on the case to get the CaseID


Case procedure icd1 case procedure icd2 case procedure icd3 case procedure icd4

Case_Procedure.ICD1, Case_Procedure.ICD2, Case_Procedure.ICD3, Case_Procedure.ICD4,

Go to Procedures and scroll to the right


Case procedure injurydate

Case_Procedure.InjuryDate

Workers Comp information, should generate across


Case procedure modifier1 case procedure modifier2 case procedure modifier3

Case_Procedure.Modifier1, Case_Procedure.Modifier2, Case_Procedure.Modifier3

Specific to your lab. Gives insurance co an added code to procedure codes. Ex. Have an S case and an N case with same procedure code, use modifier to explain to the ins. Co this is NOT a duplicate charge


Case procedure procedurecode

Case_Procedure.ProcedureCode


Case procedure whereperformed

Case_Procedure.WherePerformed

For labs with multiple laboratory sites

Press F3 to get a drop down list of locations


Patientpayor payornumber 2 patientpayor subscribername 3 patientpayor comment

Most of the PatientPayor table is found in the Billing Data Tab in Patient Demographics

PatientPayor.PayorNumber2. PatientPayor.SubscriberName3. PatientPayor.Comment

4. PatientPayor.RelatedPayorNumber5. PatientPayor.GroupNumber 6. PatientPayor. Authorization 7. PatientPayor.SignatureSourceCode

4

1

5

8. PatientPayor. SubscriberBirthDate9. PatientPayor.SubscriberSocSecNo

6

7

2

8

9

3


Patientpayor patientnumber patientpayor subscribersex patientpayor subscribersocsecno

PatientPayor.PatientNumber, PatientPayor.SubscriberSex, PatientPayor.SubscriberSocSecNo

These 3 items from the Patient Payor Table are found on the Demographics Tab in the Patient Demographics area


Cortex gold audit report decoder

Most of the Patient Table can be found on the Demographics tab in the Patient Demographics area.

Press the … button to get to Pt. Demographics!

  • Patient.Name

  • Patient.SocialSecurityNo

  • Patient.MedicalRecordNo

  • Patient.Address1

  • Patient.Address2

  • Patient.City

  • Patient.State

  • Patient.Zip

4

1

5

6

8

7

2

3


Actions

“Actions”

  • Insert

  • View

  • Delete

  • Update


Cortex gold audit report decoder

Items audited when a case is first created.

At PSMG the Internal Procedure Code for 88175 = 1003


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AUDIT_REPORT: Run by Accession number

Created a new case for this patient.

Look at your Cases & Case_Procedure Table Audit Decoder


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Diagnosis tab:

Cytotech Adds Diagnosis Code, Quality Code and initials in the grid

Coding tab:

Special Status code added


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Cytotech entering dx in the grid

Date and time case saved after modification

Whoever Modifies the case will be tracked in this column (This is a test case, so Hsousa is the only person modifying data)

View:

Tracks cases that have just been Opened

Dx area code for “Quality” = 40003 Dx Code for “Satisfactory for Eval” = 148 Cytotech is the highest ranked screener, therefore PrimayFlag = Y

Control Number is always 1 for Cytology

Cytotech’s Staff ID = 0009 (Deryl) StaffTypeCode = 1 (cytotech)

Added Special Status code # 27 = “HPV Test Ordered”

Dx area code for “Diagnosis” = 40000 Dx Code for Low Grade = 173 Cytotech is the highest ranked screener, therefore PrimayFlag = Y


Cortex gold audit report decoder

Diagnosis Tab

Pathologist Dx and initials in the grid, completed date, saved

Requisition Tab

2nd Procedure Code added :Physicians interpretation (auto inserted see Lab Pref)


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Old Value

New Value

Case_Diagnosis Table

Must Delete Old Values first

Old Values are re-Inserted

Except Cytotech is no longer highest ranking screener (Primary Flag=N)

Pathologist = ScreenerType 2 Path argreed with Cytotech, see Diagnosis Codes are unchanged (148, 173)

New Information is also Inserted (Pathologist’s dx in the grid)

Pathologist is the Primary Screener=Y

Case was completed, and the Status Code changed from “50000” = Open to “500006” = Completed/Locked.


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Old Value

New Value

Case_Screener Table

Must Delete Old Values first

Old Values are re-Inserted

Except Cytotech is no longer highest ranking screener (Primary Flag=N)

Cytotech StaffID

New Information is also Inserted (Pathologist’s dx in the grid)

Pathologist is the Primary Screener=Y

Path StaffID

Case_Procedure Table

Must Delete Old Values first

Old Values are re-Inserted

2nd Procedure code is added: 1023 = Physicians Interpretation code.

Case viewed by new Staff “lmcomber”, StaffID “0026”


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Print Case and go to Print Job Viewer

Scroll to the right to get these audited fields


Notes on the print job table

Notes on the Print Job Table

  • Think of it as a “holding bin”.

  • There are many ways from many screens to print a report in Gold.

  • The AUDIT_REPORT takes a “snap shot” of how the report is printed but this information is not necessarily available to see in the case. Pay attention to the Modified Time…everything is done at once.

  • The best way to Track printing is to use the Tracking/Files Tab in Case Management. See Print Tracking below.


Cortex gold audit report decoder

Printed Case (pg 1)

Old Value

Status is changed from Locked: 50006 to Final Print: 50008

New Value

Print Job billed by llaman.

PrintJob Table

Print Job has been printed by PSMG Print server

Delete old values

Update using Print server from system Status Code “270004=Ready” to “270001 = Processing”


Cortex gold audit report decoder

Printed Case (pg 2)

Old Value

New Value

PrintJob Table

Insert New Values

System Code Source = ClinLocation:370003

System Code Status = Ready: 270004 (Shown out of order. Here Ready “270004” is inserted, on the prior page it was Updated from Ready “270004” to Processing “270001”, and then once the print job was finished Processing “270001” was Deleted.)

System Code Type = Printer: 230003

Final Print = Y (The box was checked to go to Final Print status. And you saw on the last slide that the case went to Final Print because the Case.StatusCode changed from 50006-Locked to 50008-Final Print)


Audit report for patient by patient number or patient name1

AUDIT_REPORT_FOR_PATIENTby Patient Number or Patient Name

Tables Audited by this Report

PatientPayorPatient

Enter Patient’s last name and choose from a list

OR

Enter the Patient Number

You may use this report to see who changed a Patient’s name or Insurance Information


Audit report by patient

Audit_Report_By_Patient

Old Value

New Value

PatientPayor.PolicyNumber is updated

And it was done by L Briggs


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