Download Documenting Your Data Entry Practices

PS Suite EMR | Data Discipline and Standardization
Work Sheet #1: Documenting Your Data Entry Practices
The following instructions are intended to guide your team through an exercise that will help you
understand your current data entry practices and help you develop a set of data standards for cancer
screening.
OBJECTIVE: Document all of the current methods used to record cancer screening data in your electronic
medical record (EMR).
HOW TO USE THIS WORK SHEET: This work sheet lists all of the criteria that can be used to identify
patients eligible for cancer screening, as well as patients who should be excluded from cancer screening.
These criteria are based on current cancer screening guidelines and recommendations. For each criterion,
there are corresponding spaces for your team to record the current methods it uses to enter the data into
your EMR. In the absence of data standards, it is likely that your team will discover that data have been
entered in a variety of ways for many of these criteria.
INSTRUCTIONS:
1.1 Establish a working group to begin the data standardization process. The participants in this
working group should be EMR users with a strong understanding of how data are currently
entered by each provider in your practice.
1.2 Schedule one or more meetings for the working group to review and complete the tables on
the following page. Consider distributing the document before the meeting, so that working
group members have an opportunity to conduct some pre-work. You may also want to
assign each section of the document to different team members.
1.3 As a team, work through the tables in the document, consolidating all the ways that data are
entered for each criterion on the list. For each criterion, you should document where the data
are recorded (i.e. which category or cumulative patient profile field is used) and how the data
is labelled (i.e., the specific type of report, or the specific terminology, code or phrasing
used). If there is a criterion without data in the EMR, simply leave the space blank. Be sure
that the team is in agreement that all of the entry methods have been documented. For an
example of how to fill out the tables, please see the SAMPLE included on page 7 of this
document.
1.4 By the end of this process you will have a complete record of all the ways that cancer
screening data are entered at your practice.
Page 2 of 11
Documenting Your Current Data Entry Practices for Cancer Screening Criteria
Breast Cancer Screening
Previous Screening Tests
Reporting Criterion
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
Mammogram results may be
received as paper records, received
through electronic lab feeds or
downloaded through other means.
To ensure that all mammogram
records can be found, it is important
to understand and document the
various ways these records are
being entered (whether manually or
automatically).
1: Click here to enter text.
Breast MRI results may be received
as paper records, through electronic
lab feeds or downloaded through
other means. To ensure that all
breast MRI records can be found, it
is important to understand and
document the various ways these
records are being entered (whether
manually or automatically).
1: Click here to enter text.
How is a personal history of breast
cancer captured in your EMR by
each provider (in which categories,
using which terms/codes)?
1: Click here to enter text.
How is a record of a double
mastectomy captured in your EMR
by each provider (in which
categories, using which
terms/codes)?
1: Click here to enter text.
History of
Double
Mastectomy
Acute Breast
Symptoms
What standardized methods does
your practice use to capture records
of acute breast symptoms?
Breast
Implants
If a woman currently has breast
implants, how would this be
captured in the EMR (in which
categories, using which
terms/codes)?
Exclusion
from Breast
Screening
In addition to the criteria listed
above (e.g., Q codes, flags), what
are some ways your team may use
EMR records to exclude patients
from breast screening?
Records of
Mammogram
s
Records of
Breast
Magnetic
Resonance
Imaging (MRI)
History of
Breast Cancer
Exclusion Criteria
Data Entry Considerations
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of
mammograms:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of breast MRIs:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List all methods for capturing records of acute breast
symptoms:
Click here to enter text.
List all methods for capturing records of current breast
implants:
Click here to enter text.
1: Click here to enter text.
2: Click here to enter text.
List additional methods for capturing records that would
exclude patients:
Click here to enter text.
Page 3 of 11
Reporting Criterion
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
If a woman is a carrier of any of the
BRCA1, BRCA2, TP53, PTEN or
CDH1 genes, how would this be
captured in the EMR (in which
category, using which terms/codes)?
List all methods for capturing records of gene mutations:
Click here to enter text.
List all methods for capturing records of gene mutations in
family members:
Click here to enter text.
Determined to
be at ≥25%
Lifetime Risk
of Breast
Cancer
If a woman has a family member who
is a carrier of any of theBRCA1,
BRCA2, TP53, PTEN or CDH1
genes, how would this be captured in
the EMR (in which categories, using
which terms/codes)?
If a woman has been assessed by
either the IBIS or BOADICEA risk
assessment tools, how would this be
captured in the EMR (in which
categories, using which
terms/codes)?
Received
Chest
Radiation
Before Age 30
If a woman received chest radiation
before age 30, how would this be
captured in the EMR (in which
categories, using which
terms/codes)?
List all methods to capture records of chest radiation before
age 30:
Click here to enter text.
Carrier of a
Deleterious
Gene Mutation
High Risk Criteria
Data Entry Considerations
First-Degree
Relative of a
Deleterious
Gene Mutation
Carrier
List all methods for capturing results of risk assessments:
Click here to enter text.
Reporting Criterion
Data Entry Considerations
Previous Screening
Tests
Cervical Cancer Screening
Pap test results may be received as
paper records, received through
electronic lab feeds or downloaded
through other means. To ensure that
all Pap test records can be found, it
is important to understand and
document the various ways these
records are being entered (whether
manually or automatically).
Records of
Pap Tests
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
1. Click here to enter text
2. Click here to enter text
3. Click here to enter text
4. Click here to enter text
5. Click here to enter text
6. Click here to enter text
Page 4 of 11
Reporting Criterion
Exclusion Criteria
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
How is a personal history of cervical
cancer captured in your EMR by
each provider (in which categories,
using which terms/codes)?
How is a record of a total abdominal
hysterectomy (a hysterectomy in
which the cervix is not retained)
captured in your EMR by provider (in
which categories, using which
terms/codes)?
If a woman is, or has ever been
sexually active, how would this
information be captured in the EMR
(in which categories, using which
terms/codes)?
In addition to the criteria listed above
(e.g., Q codes, flags), what are some
ways your team may use EMR
records to exclude patients from
cervical screening?
List all methods for capturing history of cervical cancer:
Click here to enter text.
Previously
Treated for
Dysplasia
If a woman was previously treated for
dysplasia, how would this be
captured in the EMR by each
provider (in which categories, using
which terms/codes)?
List all methods for capturing records of dysplasia:
Click here to enter text.
Immunodeficiency
If a woman is immunocompromised
how is this captured in the EMR by
each provider (in which categories,
using which terms/codes)?
History of
Cervical
Cancer
History of
Total
Abdominal
Hysterectom
y
No History of
Sexual
Activity
Exclusion
from Cervical
Screening
Increased Risk
Criteria
Data Entry Considerations
List all methods for capturing history of total abdominal
hysterectomy:
Click here to enter text.
List methods for capturing records indicating the status of
sexual activity:
Click here to enter text.
List all other methods for capturing records that would
exclude patients from cervical screening:
Click here to enter text.
List all methods for capturing records of immunodeficiency:
Click here to enter text.
Page 5 of 11
Colorectal Cancer Screening
Data Entry Considerations
List All Current Methods of Data Entry if Applicable (include
EMR data field/category and terminology/code)
FOBT results may be received as
paper records, received through
electronic lab feeds or downloaded
through other means. To ensure
that all FOBT records can be found,
it is important to understand and
document the various ways these
records are being entered (whether
manually or automatically).
1: Click here to enter text.
Colonoscopy results may be
received as paper records, through
electronic lab feeds or downloaded
through other means. To ensure
that all colonoscopy records can be
found, it is important to understand
and document the various ways
these records are being entered
(whether manually or
automatically).
1: Click here to enter text.
Flexible sigmoidoscopy results may
be received as paper records,
through electronic lab feeds or
downloaded through other means.
To ensure that all flexible
sigmoidoscopy records can be
found, it is important to understand
and document the various ways
these records are being entered
(whether manually or
automatically).
1: Click here to enter text.
How is a personal history of
colorectal cancer captured in your
EMR by each provider (in which
categories, using which
terms/codes)?
1: Click here to enter text.
History of
Colorectal
Cancer
History of
Total
Colectomy
How is a record of a total colectomy
captured in your EMR by each
provider (in which categories, using
which terms/codes)?
1: Click here to enter text.
Exclusion
from
Colorectal
Screening
In addition to the criteria listed
above (e.g., Q codes, flags), what
are some ways your team may use
EMR records to exclude patients
from colorectal screening?
Reporting Criterion
Previous Screening Tests
Records of
Fecal Occult
Blood Tests
(FOBTs)
Records of
Colonoscopie
s
Exclusion Criteria
Records of
Flexible
Sigmoidoscopies
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of FOBTs:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of
colonoscopies:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of flexible
sigmoidoscopies:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
1: Click here to enter text.
2: Click here to enter text.
List all additional methods for capturing records that would
exclude patients:
Click here to enter text.
Page 6 of 11
Reporting Criterion
Data Entry Considerations
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
High Risk Criteria
1: Click here to enter text.
First-Degree
Relative with
History of
Colorectal
Cancer
If a patient has a first-degree relative
with a history of colorectal cancer,
how would this information be
captured in the EMR by each
provider (in which categories, using
which terms/codes)?
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing family history of
colorectal cancer:
Click here to enter text.
Page 7 of 11
Documenting Your Current Data Entry Practices for Cancer Screening Criteria
Breast Cancer Screening
Previous Screening Tests
Reporting Criterion
Records of
Mammogram
s
Records of
Breast
Magnetic
Resonance
Imaging (MRI)
Exclusion Criteria
History of
Breast Cancer
Data Entry Considerations
List All Current Methods of Data Entry if Applicable (include
EMR data field/category and terminology/code)
Mammogram results may be
received as paper records, received
through electronic lab feeds or
downloaded through other means.
To ensure that all mammogram
records can be found, it is important
to understand and document the
various ways these records are
being entered (whether manually or
automatically).
1: Diagnostic Imaging > Mammogram
Breast MRI results may be received
as paper records, through electronic
lab feeds or downloaded through
other means. To ensure that all
breast MRI records can be found, it
is important to understand and
document the various ways these
records are being entered (whether
manually or automatically).
1: Diagnostic Imaging > Misc. MRI Scan containing
“Breast”
How is a personal history of breast
cancer captured in your EMR by
each provider (in which categories,
using which terms/codes)?
History of
Double
Mastectomy
How is a record of a double
mastectomy captured in your EMR
by each provider (in which
categories, using which
terms/codes)?
Acute Breast
Symptoms
What standardized methods does
your practice use to capture records
of acute breast symptoms?
Breast
Implants
If a woman currently has breast
implants, how would this be
captured in the EMR (in which
categories, using which
terms/codes)?
Exclusion
from Breast
Screening
In addition to the criteria listed
above (e.g., Q codes, flags), what
are some ways your team may use
EMR records to exclude patients
from breast screening?
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of
mammograms:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of breast MRIs:
Click here to enter text.
1: History of Past Health > “Breast Cancer”
2: Problem List > “Breast Cancer”
3: Problem List > ICD-9 (174)
1: History of Past Health > “Mastectomy”
2: History of Past Health > “Double Mastectomy”
3: Click here to enter text.
List all methods for capturing records of acute breast
symptoms:
Problem Lis > “Breast Pain”
Problem List > “Breast Lump”
List all methods for capturing records of current breast
implants:
History of Past Health > “Breast Implants”
1: Bills: Service Code > Q141A
2: Risk > “No Mammo”
List additional methods for capturing records that would
exclude patients:
Risk > “No Breast Screen”
Page 8 of 11
Reporting Criterion
High Risk Criteria
Carrier of a
Deleterious
Gene Mutation
First-Degree
Relative of a
Deleterious
Gene Mutation
Carrier
Data Entry Considerations
If a woman is a carrier of any of the
BRCA1, BRCA2, TP53, PTEN or
CDH1 genes, how would this be
captured in the EMR (in which
category, using which terms/codes)?
If a woman has a family member who
is a carrier of any of the BRCA1,
BRCA2, TP53, PTEN or CDH1
genes, how would this be captured in
the EMR (in which categories, using
which terms/codes)?
Determined to
be at ≥ 25%
Lifetime Risk
of Breast
Cancer
If a woman has been assessed by
either the IBIS or BOADICEA risk
assessment tools, how would this be
captured in the EMR (in which
categories, using which
terms/codes)?
Received
Chest
Radiation
Before Age 30
If a woman received chest radiation
before age 30, how would this be
captured in the EMR (in which
categories, using which
terms/codes)?
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
List all methods for capturing records of gene mutations:
Risk > “BRCA”
History of Past Health > “BRCA”
History of Past Health > “PTEN”
List all methods for capturing records of gene mutations in
family members:
Family History > “Mom BRCA”
Family History > “M BRCA”
Family History > “Sister Breast Cancer Gene”
Family History > “Daughter PTEN”
Family History > “1st Degree Relative CDH1”
List all methods for capturing results of risk assessments:
Risk > “IBIS”
Risk > “BOADICEA”
List all methods for capturing records of chest radiation
before age 30:
History of Past Health > “Chest Rad”
Risk > “Chest Radiation”
Reporting Criterion
Data Entry Considerations
Previous Screening
Tests
Cervical Cancer Screening
Pap test results may be received as
paper records, received through
electronic lab feeds or downloaded
through other means. To ensure that
all Pap test records can be found, it
is important to understand and
document the various ways these
records are being entered (whether
manually or automatically).
Records of
Pap Tests
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
1: Diagnostic Test Reports > Pap Test Report
2: Lab Values > Pap Smear
3: Lab Text > Containing “PAP”
4: Lab Text > Containing “Cytopathology”
5: Lab Text > Containing “Cervical Smear”
6: Lab Text > Containing “Cytotechnologist”
Page 9 of 11
Reporting Criterion
Exclusion Criteria
History of
Cervical
Cancer
History of
Total
Abdominal
Hysterectom
y
No History of
Sexual
Activity
Increased Risk
Criteria
Exclusion
from Cervical
Screening
Previously
Treated for
Dysplasia
Immunodeficiency
Data Entry Considerations
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
How is a personal history of cervical
cancer captured in your EMR by
each provider (in which categories,
using which terms/codes)?
How is a record of a total abdominal
hysterectomy (a hysterectomy in
which the cervix is not retained)
captured in your EMR by each
provider (in which categories, using
which terms/codes)?
If a woman is, or has ever been
sexually active, how would this
information be captured in the EMR
(in which categories, using which
terms/codes)?
In addition to the criteria listed above
(e.g., Q codes, flags), what are some
ways your team may use EMR
records to exclude patients from
cervical screening?
List all methods for capturing history of cervical cancer:
1: History of Past Health > “Cervical Cancer”
2: Problem List > “Cervix Cancer”
3: History of Past Health > ICD-9 (180)
List all methods for capturing history of total abdominal
hysterectomy:
1: History of Past Health > “Hysterectomy”
2: History of Past Health > “TAH”
If a woman was previously treated for
dysplasia, how would this be
captured in the EMR by each
provider (in which categories, using
which terms/codes)?
If a woman is immunocompromised
how is this captured in the EMR
across all providers (in which
categories, using which
terms/codes)?
List all methods for capturing records of dysplasia:
1: History of Past Health > “Dysplasia”
2: History of Past Health > “Dys”
List methods for capturing records indicating the status of
sexual activity:
Risk > “Sexually Active”
List all other methods for capturing records that would
exclude patients from cervical screening:
1: Bills: Service Code > Q140A
2: Risk > “No PAP”
List all methods for capturing records of immunodeficiency:
1: History of Past Health > “Immuno”
2: Problem List > “HIV”
Page 10 of 11
Colorectal Cancer Screening
Data Entry Considerations
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
FOBT results may be received as
paper records, received through
electronic lab feeds or downloaded
through other means. To ensure
that all FOBT records can be found,
it is important to understand and
document the various ways these
records are being entered (whether
manually or automatically).
1: Lab Values > Stool Occult Blood
Colonoscopy results may be
received as paper records, through
electronic lab feeds or downloaded
through other means. To ensure
that all colonoscopy records can be
found, it is important to understand
and document the various ways
these records are being entered
(whether manually or
automatically).
1: Diagnostic Test Reports > Colonoscopy
1: Diagnostic Test Reports > Sigmoidoscopy
Records of
Flexible
Sigmoidoscopies
Flexible sigmoidoscopy results may
be received as paper records,
through electronic lab feeds or
downloaded through other means.
To ensure that all flexible
sigmoidoscopy records can be
found, it is important to understand
and document the various ways
these records are being entered
(whether manually or
automatically).
How is a personal history of
colorectal cancer captured in your
EMR by each provider (in which
categories, using which
terms/codes)?
1: History of Past Health > “Colon Cancer”
History of
Colorectal
Cancer
History of
Total
Colectomy
How is a record of a total colectomy
captured in your EMR by each
provider (in which categories, using
which terms/codes)?
1: History of Past Health > “Colectomy”
Exclusion
from
Colorectal
Screening
In addition to the criteria listed
above (e.g., Q codes, flags), what
are some ways your team may use
EMR records to exclude patients
from colorectal screening?
Reporting Criterion
Exclusion Criteria
Previous Screening Tests
Records of
Fecal Occult
Blood Tests
(FOBTs)
Records of
Colonoscopie
s
2: Lab Text > Containing “Fecal Occult”
3: Lab Text > Containing “FOBT”
List additional methods for capturing records of FOBTs:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of
colonoscopies:
Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
List additional methods for capturing records of flexible
sigmoidoscopies:
Click here to enter text.
2: Problem List > “Bowel Ca”
3: History of Past Health > ICD-9 (153)
2: History of Past Health > “Total Colectomy”
3: Click here to enter text.
1: Bills: Service Code > Q142A
2: Risk > “No FOBT”
List all additional methods for capturing records that would
exclude patients:
Click here to enter text.
Page 11 of 11
Reporting Criterion
Data Entry Considerations
List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
High Risk Criteria
1: Family History > “Father Colon Ca”
First-Degree
Relative with
History of
Colorectal
Cancer
If a patient has a first-degree relative
with a history of colorectal cancer,
how would this information be
captured in the EMR by each
provider (in which categories, using
which terms/codes)?
2: Family History > “Sister Bowel Cancer”
3: Family History > “1st Degree Relative Colorectal
Cancer”
List additional methods for capturing family history of
colorectal cancer:
Click here to enter text.