Principle: | Procedure: | References:
There are two databases involved in the electronic communication of patient information. The CLICS database has ADT (Admit, Discharge, Transfer) and most of the order information, while SafeTrace Tx® has a repository of patients that have had past blood bank work. ADT and order information from CLICS is automatically received into a SafeTrace Tx® holding table. This procedure addresses the process used to electronically retrieve this information, or during computer downtime, to manually enter this information into the SafeTrace Tx® system.
1. In the Patient/Order module, on the tool bar, the last square on the right is an e/E. If the E is capitalized there is an electronic order pending in the file. Click on the E button to electronically receive ADT and order information. The Pending Electronic Order Screen appears.
2. Click on “Query”.
All blood bank electronic orders from the holding table display.
Note: It is possible to limit the search by entering the patient MR number or the service provider but this eliminates other test requests that may be received (e.g.: DIM or LOW).
A. Check to see if demographic information on this patient from the holding table already exists in SafeTrace.
B. Scroll to find the Patient and Tests listed on the requisition.
C. When the patient is located from the scroll list, select it (highlight) and tests ordered in the LIS for that patient appear in the lower frame of the window.
A. If the selected (highlighted) patient has no # in the Patient ID column and no Patient-At-A-Glance bar next to the MR No. field the patient probably is new to SafeTrace. Click “OK” on the highlighted patient. The Open Patient window opens with ADT information:
B. Click “Query” to search the SafeTrace database for this patient.
a. If there is a possible match in the database, the Patients grid at the bottom of the window fills in with the possible matches. See Existing Patient in SafeTrace 4.C.b.
b. A Gnomatch message window means this is a new patient to SafeTrace:
c. Click “OK” to acknowledge this message.
C. Click “NEW” to set up a new patient profile using the ADT information.
D. The Open Patient from ADT Holding window opens with ADT information filled in. Click “Query” to search the ADT Holding Table for other possible ADT matches for this patient (MA patient now admitted; Nursing home patient now admitted):
E. Select (highlight) the ADT Holding Patient in the lower grid that exactly matches the ADT information in the top of the window and the requisition in your hand. Click “OK”. The New Patient – Using ADT Holding Defaults window opens:
F. Again, verify the information and fill in any additional information (e.g.: admission date). Click “OK”.
a. If a patient Birthdate matches another patient - “Display Duplicate Patients: window opens:
b. Viewing screen only – no action required. If patient is an actual duplicate, a blood bank administrator will merge the records after SafeTrace creates a report during the nightly update session. Click “OK”.
G. The Patient Profile window opens. See Patient Profile.
A. If the selected (highlighted) patient has a # in the Patient ID column and a Patient-At-A-Glance bar next to the MR No. field this patient exists in the SafeTrace database:
B. Click “OK” to the chosen patient. The Open Patient window opens with the SafeTrace Patient ID filled in:
C. Click “Query”.
a. SafeTrace compares all current ADT information from the ADT holding table with information it already has in its database. If all patient information matches the patient’s last visit - the Patient Profile opens. See Patient Profile.
b. If there has been an update to the patient’s information since the last visit (e.g.: different Provider, new account #) the Open Patient window appears with ADT information in the top of the grid and possible matching patients in the lower section of the grid:
c. If three patient identifiers match and there are no mismatches with other unique patient data, click “OK”. Patient identifiers include: last name, first name (derivations are considered a match – Jennifer/Jenny), birthdate, social security number, or medical record number.
Different Medical Record numbers are not considered a mismatch if each number is associated with a different Provider. A Medical record number may be a social security number or a unique number assigned by a hospital or clinic Provider. Each Provider assigns their own medical record number, so Finley’s is different from Mercy’s, which is different from Medical Associates’.
d. Each visit the patient has had in the past is an option. Selecting any option brings up the same Patient Profile.
e. C/P – The C (Current) / P (Previous) column indicates if the patient had a previous visit and one of the identifying elements has changed (e.g.: different Provider).
Warning: Three matches are required to link information in the ADT holding table to patient information already existing in SafeTrace.
f. The Accept Patient Possible Match window opens if there is any change (account #, Provider) with the identification fields juxtaposed:
g. Recheck all information:
1. If correct click “Yes”.
2. If incorrect click “Cancel”.
Do not click “No” – this takes you to the existing patient’s file with no link to the new patient to bring in.
1. The specimen and requisition(s), or the Supplier’s “coming” Autologous unit report, arrive in Blood Bank. If the interface is not working, or you wish to enter patient information without an electronic order (e.g.; entering Autologous/Directed information prior to the patient admission), the Blood Bank operator manually enters patient information from the Requisition/Auto report into SafeTrace by choosing File (menu bar); New; Patient:
2. The Open Patient window opens:
3. Move the cursor to the Patient demographic area and enter any information known; click “Query”.
A. Possible Matching patient – see Existing Patient in SafeTrace 4.C.b.
B. If SafeTrace doesn’t have any records that might match up based upon the Query information entered, the “Gnomatch” message appears:
C. Click “OK” to acknowledge this message.
4. Click “NEW”.
A. If there are no possible matches in the ADT Holding table, the “New Patient” window opens:
a. Enter all information known. Visit information is not required for Autologous/Directed entries. (SafeTrace prompts the user to fill the required fields.)
b. Click “OK”. The “Patient Profile” window opens. See Patient Profile.
B. If there is a possible match in the ADT Holding table the “Open Patient from ADT Holding” window displays:
a. “Query” – possible ADT Match
1. The possible matches in the ADT holding table will be listed in the grid in the lower section of the window:
2. If there is a matching patient, select the patient and click “OK”. The “New Patient - using ADT Holding Defaults” window opens:
3. Verify the information and fill in any additional information (e.g.: admission date). Click “OK”. If a patient Birthdate matches another patient – “Display Duplicate Patients” window opens.
Note: This is a viewing screen only - no action required. If patient is an actual duplicate, a blood bank administrator will merge the records after SafeTrace creates a report during the nightly update session.
b. “Query” – No ADT match. Click “None” if there are no matches – the “New Patient” window opens (see above).
SafeTrace takes the information entered electronically or manually and creates a Patient Profile with an identification number (Patient ID) unique to SafeTrace. This ID is exclusive, permanent and is used to track a patient’s total blood bank history. All testing, products received, problems, derivatives received, special needs, comments, transfusion reactions, specimens used, techs and phlebotomists involved, can be traced with this number. The Patient Profile automatically opens after patient information is entered, either by ADT feed or manual entry. It also may be opened at any time by going to File (Menu Bar), Open, Patient. The Patient Profile always opens on the “General” Screen.
1. The “General” index tab is active and general patient information displays.
2. Review ALL the patient information, make any corrections that may be necessary, and “Save” by clicking on the disk icon
3. Examine the Patient-At-A-Glance bar (PAAG bar): All patient history is condensed here. Any capital letter on the PAAG bar indicates important patient information and needs to be reviewed before any work is done on this patient. The PAAG bar is the most important tool SafeTrace contains:
A. s/S: Special Needs. Click on the capital S to see a patient’s special needs: Once a special need is identified for a patient, only products meeting the special need can be issued to that patient. If a Special Need is no longer required, it must be end-dated. See Edit Patient Special Needs.
B. c/C: Comments. Click on a capital C to see patient related comments. These comments are informational. Use this option to notify others that auto units are coming for this patient. Also, use this option to inform other techs of problem resolution (e.g.: use Saline technique; or, prewarm testing). SafeTrace does not use comments to limit products or require testing. See Edit Patient Comments.
C. x/X: Transfusion Reaction. Click a capital X to see the resolution of a transfusion reaction. (For converted records a capital X indicates some transfusion notes were recorded.)
D. a/A: Autologous unit. Click a capital A to see the autologous unit(s) that is in inventory for this patient. SafeTrace does not allow the issue of a homologous unit when there is an autologous unit in inventory.
E. d/D: Directed unit. Click a capital D to see directed units linked to this patient. SafeTrace does not allow the issue of a homologous unit when a directed unit for the patient is in inventory: See above. The same information screen is used for autologous and directed units.
F. aby/ABY: Antibody(ies). Click on a capital ABY to see a patient’s extended typings (antibody history). The aby becomes ABY as soon as an antibody is identified on the result screen. SafeTrace does not allow the issue of an antigen untested unit to a patient that has an antibody.
G. Blood Group & Type field. Any patient with any history has a group and type displayed. Click on the group and type field and extended typings display.
H. Specimen field. If the patient has a current specimen, an outdate for that specimen appears in this field, otherwise the field is blank. Click the specimen field to see a history of all specimens registered for that patient. When performing any add on testing, always review the current specimen detail to verify the accession number and draw date. See Edit Patient Specimens.
I. r/R:Reserved unit. Click on a capital R to see a reserved unit for that patient. Special request units from the supplier are reserved for the patient at delivery (e.g.: antigen negative, CMV negative, irradiated).
J. Converted: Y or N: A “Y” here means the patient has converted data from the historical records before SafeTrace. See “Patient History: Converted Data”. An “N” here means the patient does not have converted data.
Below the PAAG Bar, tabs relating to other patient information screens are located. Many tabs duplicate the PAAG Bar. These are explained below:
A. General – Patient Profile’s opening screen. General patient information screen.
B. Comments – patient comments screen also displayed from c/C on the PAAG bar.
C. Extended Typings – patient antibodies and antigens screen also displayed from aby/ABY and Group and Type fields on the PAAG bar.
D. Special Needs – patient special needs screen also displayed from s/S on the PAAG bar.
E. TxRx – patient transfusion reaction history also displayed from x/X on the PAAG bar.
F. Specimen – patient specimen history also displayed from the specimen outdate field on the PAAG bar.
G. Tests - patient test history. Select the “Show All” option to view all testing done on the patient.
A. Products received by a patient are not on the Patient Profile screen, but can be accessed with the Patient Profile window open by going to Product (Menu Bar); Patient Order Inquiry.
B. The Patient Order Inquiry screen opens with “Components” as the chosen option. (To see the Derivatives history (RhoGam/MicRhogam) select the “Derivatives” tab and follow the same steps.)
C. Type in the Patient Id from the open Patient Profile window (can grab and drag the title bar of the “Patient Order Inquiry” window to view the Patient Profile behind it - or use the “Find” button) and select “All” under Order Component Status (the default is “Ready to Issue” – so questions from the floor about units set on a patient can be readily answered). Hit “Query”. The Patient Order Inquiry now lists all components associated with the patient.
D. Close the window once product for this patient has been reviewed.
A. Click “General” Tab to review visit information.
B. New Patient in SafeTrace: Visit information automatically fills Current Visit Information box on the Patient Profile window.
C. Previous Patient in SafeTrace – Last visit information is shown in the Current Visit Information box on the Patient Profile window.
a. Same visit, added tests – no visit update needed.
b. Different visit:
1. Discharge Date: Type today’s date in for a discharge date (can type “d” tab). Save.
2. New Visit: Go to File (menu bar); New; Visit. The New Patient Visit window opens:
3. Click “ADT Visit…” The ADT Visit Holding window opens with the new visit information.
4. Highlight the visit with the correct admission date (in the event more than one visit option is listed) and Click “OK”. The New Patient Visit window populates with the ADT information. Click “OK” and the Patient Profile opens with the updated visit information.
7. Edit Patient Comments
The Comments section is a free text window used to relay significant information pertaining to the patient. Whenever an autologous/directed informational sheet is received from the blood center, a comment must be entered. Any hints or testing problems are also entered as comments (e.g.: Prewarm all tests; use Saline technique per Reference Lab, etc). End-date all comments no longer valid (i.e.; after the Autologous units have been crossmatched). An additional comment is required to explain the end-date. Patient Comments may be edited at any time, with or without patient work.
A. Go to Edit (menu bar); Edit Patient Comments:
B. The Patient Comments window opens:
C. Enter the description in free text (e.g. Autologous unit coming), then click “OK”. The PAAG bar will now have a C instead of c.
Note: All Pre Admit Autologous/Directed entries need a Comment entered alerting users of Autologous/Directed units coming. This is the only warning that a patient has donated Autologous blood (or has a Directed unit coming) and it is not in our inventory.
8. Edit Patient’s Special Needs
Whenever a physician orders a special product for a patient (CMV negative, irradiated) that patient’s Special Needs section must be updated. To discontinue a Special Need, an end-date must be entered along with a comment explaining why the Special Need was discontinued. Patient’s Special Needs may be edited at any time, with or without patient work.
B. The Patient Special Needs window opens.
Use “Find” to select the Need ID (e.g.: CMV Negative), and then click “OK”. The PAAG bar now has an S instead of s. The S becomes an s after a Special Need is end-dated. CSafeTrace needs a 24 hour cycle to register the change.)
9. Edit Patient Specimens
Whenever a specimen is received in the Blood Bank for testing, it must be registered to the patient before an order is processed. SafeTrace then assigns the specimen an expiration date and bases allowable testing and validity of crossmatch tests on this expiration date. SafeTrace automatically takes units out of crossmatch (Released to Available) when the specimen expires. A valid specimen has an expiration date on the PAAG bar.
Note: If the order is for a product that does not require a specimen for issue (platelets, Cryo, FFP), a specimen need not be registered.
A. Go to Edit (menu bar); Edit Patient Specimens:
B. The Patient Specimen window opens showing all registered specimens.
a. To use a valid Specimen already registered, compare the accession number and draw date and time of the Blood Bank specimen with the information in the Specimen window. Highlight the specimen to use. “Close” the window.
b. If there is no current specimen, click “New”. The New Specimen window opens.
c. Bar-code, or manually type in the UCL Accession #. The Accession # is the ABO or GTS Accession number and that should be the only Accession # on the tube. This Accession # is the Specimen identification number for the life of the specimen. DO NOT place additional blood bank accession #s on this tube.
d. Fill in the Emergency ID # (e.g. Typenex #) in the External ID box, if applicable (Trauma patients or Outpatients).
e. The Specimen Type defaults to R (Routine). If the specimen is not routine, choose the type needed by pulling down the options menu and choosing the appropriate code.
1. R (Routine): specimen drawn on routine patients that will expire in 3 days.
2. N (Neonatal): specimen drawn on neonatal patients that will expire in 4 months.
3. P (Pre-admit): specimen drawn on PAT patients that will expire in 14 days.
4. A (Autologous): specimen drawn from patient’s known to have autologous units available. This allows the Auto units to stay set for the life of the units. This specimen type cannot be used if Homologous units are also set.
f. The Specimen Status defaults to AV (Available). Do not use any other status. If there is a specimen problem follow the UCL Specimen policy and make appropriate entries in the Incidence Log.
g. Fill in the Draw Date and Time. The Expiration Date and Time populates automatically according to the Type of Specimen.
h. Deselect (un-√) the Print Label box; click “OK”.
i. The Patient Specimen window appears with the new specimen information recorded; click “Close”.
j. The PAAG bar now has the expiration date of the current specimen filled in.
10. Patient Order
A Patient’s Visit must be correct (See Review Visit Information) and a specimen (if required) needs to be registered (See Edit Patient Specimens) BEFORE any orders are placed.
To initiate an order for tests and/or products:
A. Go to File (menu bar); New; Order; Regular:
B. The New Order window opens.
C. Recheck the information, including the Specimen ID#. Correct any misinformation.
Note: If the order is for a product that does not require a specimen for issue (platelets, Cryo, FFP), no specimen needs to be registered. If there is no current specimen for this patient, there must be no Specimen ID # in this field. If there is a specimen #, delete it. (This is the only way that the SafeTrace Tx® system will allow for the release of these products without a factor override.)
D. Click “OK”.
E. The Order Profile window opens:
F. Check the information. FILL IN THE TIME RECEIVED. (Type a “t” in this field and tab. This automatically writes the current time in the space.)
Warning: If the Received Time is not entered BEFORE ordering tests, it will be necessary to record the time for EACH order item.
1. Pull down the Orders menu.
2. Choose: Add Electronic Orders.
3. The Select Pending Electronic Order Screen appears:
4. The orders linked to the patient’s ADT and visit information are available for selection. Compare these orders to the requisitions.
If the hard copy requisition and the electronic order in SafeTrace do not match, check pending electronic orders for an add-on order and retrieve that order separately.
If the requisition and the electronic order in SafeTrace match - continue.
5. Select (highlight) the order item(s) on the grid at the bottom of the window. The “Notes” button activates if a comment is included on the order item. If the “Notes” button is active click on it to review any pertinent comments (Send Product if Negative, Quantity for Crossmatch(es)). If the “Notes” button is inactive go to # 7.
6. Click on “Close”.
7. Select all the orders in the top grid. Choose multiple rows by using the control key. Click on “OK”.
8. If a Rhogam or MicRhogam product is ordered a volume needs to be entered (300 - Rhogam; 50 - MicRhogam).
9. Save the orders by clicking on the disk icon. (This registers the electronic order in SafeTrace.)
1. Move the cursor to the Items grid – Type box:
2. Fill in the Type code (use “Find” - the binoculars icon).
3. Fill in the Item ID code (use “Find” - the binoculars icon).
4. Fill in the quantity needed.
5. If a Rhogam or MicRhogam product is ordered a volume needs to be entered (300 – Rhogam; 50 – MicRhogam).
6. If more than one order is needed, add more Item row(s) by clicking “Tab” all the way through the first Item row, causing a second row to appear. Repeat until all orders are entered.
Note: When RBCs are ordered, the appropriate numbers of Crossmatch orders are automatically added.
7. Fill in the Priority field.
8. Save the orders by clicking on the disk icon.
G. Exit the Order Profile by clicking the small x box in the upper right corner of the window.
H. Exit the Patient Profile by clicking the small x box on the upper right corner of the window.
Warning: Do not click the very upper right corner of the screen – that is the “Close” button for the entire Patient Order Module.
1. SafeTrace Tx® Patient Order Training Manual 04/03/2001.
2. Wyndgate communications 2001 - 2002
i. September 2003 M. Burger, N. Combs, S. Raymond, S. Rodriguez
Interim Review: February 2011 N. Combs (no change)