Page 1 of 11
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 yourelectronic 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 methodsit uses to enter the data into yourEMR. 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:
1.1Establish 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.
1.2Schedule 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 membershave an opportunity to conduct some pre-work. You may also want to assign each section of the document to different team members.
1.3As 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 withoutdata 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 outthe tables, please see the SAMPLE included on page 7of this document.
1.4By the end of this process you will have a complete record of all the ways that cancer screening data are entered at your practice.
Breast Cancer ScreeningDocumenting Your Current Data Entry Practices for Cancer Screening Criteria
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable(include EMR data field/category and terminology/code)
Previous Screening Tests / Records of Mammograms / 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.
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.
Records of
Breast Magnetic Resonance Imaging (MRI) / 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.
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.
Exclusion Criteria / History of Breast Cancer / 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.
2: Click here to enter text.
3: Click here to enter text.
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)? / 1: Click here to enter text.
2: Click here to enter text.
3: Click here to enter text.
Acute Breast Symptoms / What standardized methods does your practice use to capture records of acute breast symptoms? / List all methods for capturing records of acute breast symptoms:
Click here to enter text.
Breast Implants / If a woman currently has breast implants, how would this be captured in the EMR (in which categories, using which terms/codes)? / List all methods for capturing records of current breast implants:
Click here to enter text.
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? / 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.
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 / Carrier of a Deleterious Gene Mutation / 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.
First-Degree Relative of a Deleterious Gene Mutation Carrier / 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)? / 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 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)? / List all methods for capturing results of risk assessments:
Click here to enter text.
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.
Cervical Cancer Screening
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
Previous Screening Tests / Records of Pap Tests / 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). /
- Click here to enter text
- Click here to enter text
- Click here to enter text
- Click here to enter text
- Click here to enter text
- Click here to enter text
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
Exclusion Criteria / History of Cervical Cancer / How is a personal history of cervical cancer captured in your EMR by each provider (in which categories, using which terms/codes)? / List all methods for capturinghistory of cervical cancer:
Click here to enter text.
History of Total Abdominal Hysterectomy / 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)? / List all methods for capturinghistory of total abdominal hysterectomy:
Click here to enter text.
No History of Sexual Activity / 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)? / List methods for capturing records indicating the status of sexual activity:
Click here to enter text.
Exclusion from Cervical 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 cervical screening? / List all other methods for capturing records that would exclude patients from cervical screening:
Click here to enter text.
Increased Risk Criteria / 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.
Immuno-deficiency / If a woman is immunocompromised how is this captured in the EMR by each provider (in which categories, using which terms/codes)? / List all methods for capturing records of immunodeficiency:
Click here to enter text.
Colorectal Cancer Screening
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable (include EMR data field/category and terminology/code)
Previous Screening Tests / Records of Fecal Occult Blood Tests (FOBTs) / 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.
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.
Records of Colonoscopies / 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.
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.
Records of Flexible Sigmoid- oscopies / 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.
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.
Exclusion Criteria / History of Colorectal Cancer / 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.
2: Click here to enter text.
3: Click here to enter text.
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.
2: Click here to enter text.
3: 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? / 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.
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 / 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)? / 1:Click here to enter text.
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.
Documenting Your Current Data Entry Practices for Cancer Screening Criteria
Breast Cancer ScreeningReporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable (include EMR data field/category and terminology/code)
Previous Screening Tests / Records of Mammograms / 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
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.
Records of
Breast Magnetic Resonance Imaging (MRI) / 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”
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.
Exclusion Criteria / History of Breast Cancer / How is a personal history of breast cancer captured in your EMR by each provider (in which categories, using which terms/codes)? / 1: History of Past Health > “Breast Cancer”
2: Problem List > “Breast Cancer”
3: Problem List >ICD-9 (174)
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)? / 1: History of Past Health > “Mastectomy”
2: History of Past Health > “Double Mastectomy”
3: Click here to enter text.
Acute Breast Symptoms / What standardized methods does your practice use to capture records of acute breast symptoms? / List all methods for capturing records of acute breast symptoms:
Problem Lis“Breast Pain”
Problem List“Breast Lump”
Breast Implants / If a woman currently has breast implants, how would this be captured in the EMR (in which categories, using which terms/codes)? / List all methods for capturing records of current breast implants:
History of Past Health“Breast Implants”
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? / 1: Bills: Service Code >Q141A
2: Risk > “No Mammo”
List additional methods for capturing records that would exclude patients:
Risk > “No Breast Screen”
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 / Carrier of a Deleterious Gene Mutation / 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:
Risk > “BRCA”
History of Past Health > “BRCA”
History of Past Health “PTEN”
First-Degree Relative of a Deleterious Gene Mutation Carrier / 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)? / 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”
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)? / List all methods for capturing results of risk assessments:
Risk > “IBIS”
Risk “BOADICEA”
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 for capturing records of chest radiation before age 30:
History of Past Health “Chest Rad”
Risk “Chest Radiation”
Cervical Cancer Screening
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
Previous Screening Tests / Records of Pap Tests / 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). / 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”
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
Exclusion Criteria / History of Cervical Cancer / How is a personal history of cervical cancer captured in your EMR by each provider (in which categories, using which terms/codes)? / List all methods for capturinghistory of cervical cancer:
1: History of Past Health “Cervical Cancer”
2: Problem List > “Cervix Cancer”
3: History of Past Health > ICD-9 (180)
History of Total Abdominal Hysterectomy / 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)? / List all methods for capturinghistory of total abdominal hysterectomy:
1: History of Past Health > “Hysterectomy”
2: History of Past Health > “TAH”
No History of Sexual Activity / 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)? / List methods for capturing records indicating the status of sexual activity:
Risk > “Sexually Active”
Exclusion from Cervical 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 cervical screening? / List all other methods forcapturing records that would exclude patients from cervical screening:
1: Bills: Service Code Q140A
2: Risk “No PAP”
Increased Risk Criteria / 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:
1: History of Past Health “Dysplasia”
2: History of Past Health “Dys”
Immuno-deficiency / 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 immunodeficiency:
1: History of Past Health “Immuno”
2: Problem List “HIV”
Colorectal Cancer Screening
Reporting Criterion / Data Entry Considerations / List All Current Methods of Data Entry if Applicable
(include EMR data field/category and terminology/code)
Previous Screening Tests / Records of Fecal Occult Blood Tests (FOBTs) / FOBT results may be received as paper records, received through electronic lab feeds ordownloaded 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
2: Lab Text Containing “Fecal Occult”
3: Lab Text Containing “FOBT”
List additional methods for capturing records of FOBTs:
Click here to enter text.
Records of Colonoscopies / 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
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.
Records of Flexible Sigmoid- oscopies / 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: Diagnostic Test Reports Sigmoidoscopy
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.
Exclusion Criteria / History of Colorectal Cancer / 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”
2: Problem List “Bowel Ca”
3: History of Past Health ICD-9 (153)
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”
2: History of Past Health “Total Colectomy”
3: 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? / 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.
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 / 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)? / 1:Family History > “Father Colon Ca”
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.