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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

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.43800 Data Input ID Phase 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.

  • 50006 Completed/Locked

  • 50008 Final Print

  • 50002 Gross Entered

  • 50004 Gross Printed

  • 50000 Open


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 sequence
Case_SpecialStatus.Sequence

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

1

2



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:

370003 ClinLocation

370006 ClinLocation Rule

370004 Copies To

370001 Designator

370002 Designator Rule

370009 Interface

370005 One-Off


Printjob systemcodestatus
PrintJob.SystemCodeStatus

Internal Codes Audited:

270005 Deleting, 270003 Error

270002 Paused, 270001 Processing , 270004 Ready


Printjob systemcodetype
PrintJob.SystemCodeType

Internal Codes Audited:

230002 Default Fax, 230001 Default Printer, 230004 Fax

230006 Interface, 230003 Printer 230008 SaveToFile

230005 Secure Delivery System

= Report Location Types


Printjob systemcodeprintfiletype
PrintJob.SystemCodePrintFileType

Internal Codes Audited

440001 Adobe PDF

440004 Post Script

440002 Word Doc

440003 Word Docx


Printjob systemcodeprintfileschema
PrintJob.SystemCodePrintFileSchema

Internal Codes Audited

430002 AccessionNumber and Clinician and Location

430003 Accession Number and Time Stamp

430001 Accession Number Only

= Print Naming Schema



Case procedure authorizationnumber
Case_Procedure.AuthorizationNumber Procedures Grid in Gold.


Case procedure billeddate
Case_Procedure.BilledDate Procedures Grid in Gold.

Go to Procedures and scroll to the right


Case procedure caseid
Case_Procedure.CaseID Procedures Grid in Gold.

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 Case_Procedure.ICD3, Case_Procedure.ICD4,

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.Modifier3


Case procedure whereperformed
Case_Procedure.WherePerformed Case_Procedure.Modifier3

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


Most of the PatientPayor.SubscriberSocSecNoPatient 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” PatientPayor.SubscriberSocSecNo

  • Insert

  • View

  • Delete

  • Update


Items audited when a case is first created. PatientPayor.SubscriberSocSecNo

At PSMG the Internal Procedure Code for 88175 = 1003


AUDIT_REPORT: Run by Accession number PatientPayor.SubscriberSocSecNo

Created a new case for this patient.

Look at your Cases & Case_Procedure Table Audit Decoder


Diagnosis tab: PatientPayor.SubscriberSocSecNo

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

Coding tab:

Special Status code added


Cytotech entering dx in the grid PatientPayor.SubscriberSocSecNo

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


Diagnosis Tab PatientPayor.SubscriberSocSecNo

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

Requisition Tab

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


Old Value PatientPayor.SubscriberSocSecNo

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.


Old Value PatientPayor.SubscriberSocSecNo

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”


Print Case and go to Print Job Viewer PatientPayor.SubscriberSocSecNo

Scroll to the right to get these audited fields


Notes on the print job table
Notes on the Print Job Table PatientPayor.SubscriberSocSecNo

  • 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.


Printed Case PatientPayor.SubscriberSocSecNo (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”


Printed Case PatientPayor.SubscriberSocSecNo (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_PATIENT PatientPayor.SubscriberSocSecNoby 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 PatientPayor.SubscriberSocSecNo

Old Value

New Value

PatientPayor.PolicyNumber is updated

And it was done by L Briggs


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