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Hospital User Manual (Queensland sites)

1. 2 Select the appropriate response from the drop down lists for each of the following questions e Was the patient transferred from another hospital e Did this stroke occur while the patient was in hospital e Was the patient able to walk independently on admission e Is there documented evidence of a previous stroke focal neurological signs persisting for more than 24 hours Important notes for recording dates The format used for date is always DD MM YYYY Each date must be marked as Accurate or Estimate by clicking the corresponding radio button If the Accurate exact date is unknown and not obtainable the Estimate radio button located below the entered date should be clicked When the day is unknown but the month and year are known the date should be recorded as 01 MM YYYY and the Estimate radio button located below the entered date should be clicked When only the year is known the date should be recorded as 01 01 YYYY and the Estimate radio button located below the entered date should be clicked Important notes for recording times e he format used for time is always the 24 hour clock with a colon automatically inserted to separate hours and minutes hh mm If an exact time cannot be recorded i e not in the chart or is unknown the best estimate should be given Descriptions of time such as two hours prior to arrival about 1 hour ago or approximately 2 and half hours ago are specific enough to
2. It is not possible to edit any errors or add to the Patient Information screen once you have pressed Save This includes the Patient s Name Date of Birth and Medicare Number To AuSCR Queensland Hospital User Version 2 0 24 07 2013 48 edit this information you should contact the AUSCR office or delete this patient and start again with the correct information If you would like to edit the stroke episode details such as date of stroke date of arrival or even type of stroke you may do so at any time up until you lock the episode Once you have completed the corrections you should save the episode and then lock the episode this will allow the person to be followed up in the community To edit the stroke episode details after you have locked an episode of care you must contact the AuSCR office However once editing is completed you must lock this episode again to permit follow up to occur There seem to be some questions missing for the patients who die in hospital The following two questions below will not appear if Died in hospital is selected as the Discharge destination mode Discharge on Antihypertensive agent gt Is there evidence that a care plan outlining post discharge care in the community was developed with the team and the patient and or family if patient has severe aphasia or cognitive impairments If Died in hospital is selected you must complete the Death Information that opens up
3. T Mailing Address Home i Address Type Street Address Select w Suburb State Postcode Please Select Country AuSCR Queensland Hospital User Version 2 0 24 07 2013 16 Patient Contacts Outcome determination is the most fundamental requirement of any clinical registry including AuSCR In AuSCR out of hospital outcomes are determined by contacting patients three months after discharge and asking a small number of key questions It is very important that we are able to contact patients after they leave hospital Therefore to avoid loss to follow up at least two alternate contacts should be recorded in addition to the patient s own address To add contacts 1 Select the contact s Title from the drop down list and type in their First Name Last Name Phone Number and Mobile Number 2 Indicate the Relationship to the patient for Emergency and Alternate Contacts by selecting one of the options in the drop down list Important note If Other Relative is selected an Other Relative text box will appear Type the relationship to the patient 3 If the Contact s address is the same as the patient address click in the Same as patient home address above tick box 4 Complete address detail entry refer to To add addresses section above Important note Once all of the data have been entered click the Save button at the bottom of the page to save the information on the Patient Record screen An
4. It is anticipated that information in the Stroke Registry will be used to further medical knowledge and improve stroke patient care After discharge all participants will have the opportunity to ask to speak with a representative of the National Stroke Foundation about available services at the end of their 3 6 month follow up However no direct benefit to you as an individual may be forthcoming from your participation in the Registry Will this affect your care The way your treating doctors and the stroke team approach your treatment and long term care will not be affected regardless of whether or not you participate in the Stroke Registry Participation is Voluntary Participation is voluntary To remove all or some of your details from the Australian Stroke Clinical Registry please use the form at the bottom of this page or contact the Stroke Registry on 1800 673 053 freecall The signed slip can be given to the nursing staff while you are in hospital or mailed at anytime to AuSCR c Public Health Stroke Division Melbourne Brain Centre 245 Burgundy Street Heidelberg VIC 3084 If you choose to remove Medical information and or Personal information on the form below you will be contacted to confirm the specific information you wish to have removed Please provide your contact details for AuSCR office staff to contact you An invitation from the Stroke Registry to participate in future research projects During your follow up you will be a
5. Other required Missing Table 10 4 Discharge Destination Mode List For further information please refer to the AuSCR Queensland Data Dictionary Discharge Destination Mode Explanation of where the patient is discharged to Transfer to another Hospital A different hospital while patient is still in the acute acute phase of care SNAP still in hospital Date of discharge from acute episode to sub acute treatment phase but still an inpatient Rehabilitation inpatient Rehabilitation unit hospital Low level Residential care Aged Care Hostel Special accommodation facility High level Residential care Nursing Home Aged Care facility Note private palliative care nursing homes may also be classified under this category Home with supports Living at home with some support structure Home without supports Living at home entirely alone Transitional care service A community based health care service program Died in Hospital Died while in hospital Other Include welfare institution such as prisons group homes e g boarding houses providing primarily welfare services Missing Documentation regarding destination is lost or was not recorded completed Important note If Died in hospital is selected the Death Information section must be completed AuSCR Queensland Hospital User Version 2 0 24 07 2013 28 Death Information Figure 10 9 1 Click the Patient decea
6. 07 2013 67 Attachment 5 Example of User Request Form AUSCHR Australian Stroke Clinical Registry AuSCR Online Tool User Request Form Please complete this form to obtain a user ID and password to be able to login to the AuSCR Online Tool reauired field Title Name Position Hospital Email Phone Signature Access Request for Tick appropriate box E Hospital Administrator E Hospital User E Follow up User Please note that this request must be authorised by the AuSCR e Project Coordinator for Hospital Administrator and Follow up User Request e Hospital Administrator for Hospital User Request Authorised by Title Email Phone Please return this form by fax or email If you have any questions please do not hesitate to contact us Project Coordinator Australian Clinical Stroke Register Email admin auscr com au AuSCR Telephone 03 9035 7264 Public Health Stroke Division Fax 03 8888 4990 245 Burgundy Street Heidelberg VIC 3084 Office Use Only Date received Date created User name Password assigned User Request Form 12 Sep 2012 v5 doc AuSCR Queensland Hospital User Version 2 0 24 07 2013 68 Attachment 6 Example of Patient Contact Letter Post Discharge AUSCH Australian Stroke Clinical Registry Date Dear xo We wish to inform you that your hospital kopini nane is participating in the Australian Stroke Clinical Registry AuSCR w
7. 24 07 2013 64 Patient Name Retty Robble pos 1 O4_197 Hospital Pavel Teneours He Admission Information Date of arrival at Emergency Department awaa AS A ddimmiyyyy Accurate Estimate Time of arrival at Emergency Department fo Tz Els 24 hour clock ui Accurate 7 Estimate o lE gazna 2 aaimmiyyyy is curate timate Time of stroke onset excl 24 hplir clock E Accurate Ktimate Date of admission bee Week 2 dd mm yyyy Ds rate Estimate Time of admission L te 2 103 5 24 nour clock S ccurate O Estimate Was the patient transferred from another hospital L Yes No L1 unknown Did this stroke occur while the patient was in hospital J Yes a fio Unknown Date of stroke onset bj Is there documented evidence of a previous stroke i e focal neurological signs persisting for more than 24 hours L Yes 1 No Unknown Able to walk independently on admission E i e may include walking aid but without assistance from C Yes No C Unknown another person Clinical Information Was the patient treated in a Stroke Unit at an time during their stay v Yes L No EL Unknown Type of stroke O TIA a J Haemorrhagic J Undetermined If an ischaemic stroke did the patient receive intravenous thrombolysis tPA Yes No C Unknown Cause of stroke O Known rafter Diagnosis QO Medica condition DOOD OOO 0000 ICD10 codes Complication DOOD OOOO OOoOo0 Procedures
8. C Opt out personal information Form completed by E JL JE JE JE YE X JE YE YE E YE E JE JCEL YE E JE pate T M VL T contact Number E E YE E E E YE T 1E AuSCR AcuteData CollectionForm Queensland V4 2 8October2013 Clean docx 44 AuSCR Queensland Hospital User Version 2 0 24 07 2013 58 Attachment 3a Example of Correctly Completed Acute Data Collection Form DATA COLLECTION FORM QUEENSLAND Australian Stroke Clinical a oles Please complete the form Return form to AuSCR Office via Neatly and legibly Fax 02 8507 2531 Write in black ink and press firmly Or Each question must be completed Post AuSCR Office c o TGI PO Box M201 Place v in appropriate boxes Missenden Road Camperdown NSW 2050 Required fields marked with must be completed Hospital Name AFFIX PATIENT STICKER HERE Patient Information Title EXEC ITIEEEEETET Map d KGB Ee YE gern JE E EC JC C JE JC Y 3E JE JC JC 3C 3C 3C 031 bast vam rto YE Le YE Y 3E 38 3E ECOL CHE JE JC JC C 3C JC JC JE ECCL 303 Address type Home L Business O Other Street Address A SAATAN Suburb E ei cene ete ter de E E 3C EC 3E EE CC JE JC JC C30 3C 10303 EJ Post Code AANA see AHACOCOOC Country ALES rr edel eg Y Y C EC C JC JC JC 4030303 Phone Number o z sie ns T EZJLS G Mobite Number 6113 TZ JT led G3 Medicare No MABAN Hospitai mRN ILLE Ei Ei P X Y YE Date of Birth eJ ve ee VOID dd
9. Data Manager from AuSCR office on behalf of the patient Hospital staff cannot opt out or remove data from the AuSCR database The opt out request occurs in two stages 1 The request by the Hospital User 2 Confirmation by the Superuser or the Data Manager To request data to be opted out for a patient 1 Search for the patient to be opted out 2 Click the hyperlinked Name for the patient to be opted out and the Patient Information screen will be displayed 3 Click the Opt out button at the bottom of the page and the Opt out page will be displayed Figure 15 1 4 Select the corresponding radio buttons of the item s the patient guardian or next of kin has requested to opt out 5 Add any comments to describe why the data are being opted out 6 Click the Save button and a warning panel will appear Figure 15 2 7 Click the Yes button to confirm the request or the No button to cancel the request It will bring you to the Opt out information save page Figure 15 3 8 The request will automatically be added to the Opt out List accessible only to Superusers and the Data Manager from AuSCR office 9 The Superuser or the Data Manager from AuSCR office will perform the actual opt out using the Opt out List during scheduled data management processes AuSCR Queensland Hospital User Version 2 0 24 07 2013 33 Important notes e f you have made a mistake or incorrectly entered a patient who did not have a stroke
10. Drop down lists a list of options from which you select Example Please Select v Drop down TESSE list name Mr Mrs Miss Ms Dr Mast e These are white boxes which contain either a default option or the words Please Select and a small blue box with a down arrow e To select an option click the down arrow and then click the option required e For large option lists you can either scroll down the list using the blue scroll bar to the right of the list click and hold the left mouse button down while moving the scroll bar down the page until the option required appears or type in the first letter s of the option you require Tick boxes a small white box in which you click to mark with a tick Example Tick box name o e Toremove the tick click in the box a second time e n some instances where it is not applicable the tick box may be inactivated Radio buttons a small white circle in which you click to mark with a dot Example Accurate Estimate e lf there is more than one radio button for a field only one button can be marked e Clicking an alternative radio button for a field will unmark all other radio buttons for that field Calendar Dates can be entered by either typing them in the text box or by using an embedded calendar to select the date The use of the embedded calendar is the preferred option in order to reduce errors Example lt lt lt Januar
11. Important note If the patient died in hospital the Date of discharge should be the same as Date of death 3 Select the appropriate option from the drop down list for each of the following questions fields e Discharge destination mode Table 10 4 Important note The following two questions below will not appear if Died in hospital is selected as the Discharge destination mode e Discharged with Antihypertensive agent e Is there evidence that a care plan outlining post discharge care in the community was developed with the team and the patient or family if patient has severe aphasia or cognitive impairments AuSCR Queensland Hospital User Version 2 0 24 07 2013 27 Figure 10 8 Discharge Information Discharge Information Iv Date of discharge known 07 06 2012 T Date of discharge Accurate Estimate SNAP erill in hasnitali Discharge destination mode Please Select Transfer to other hospital Discharge on Antihypertensive agent SNAP srill in hospital Hospital Rehabilitation Inpatient Discharged on an antiplatelet antithrombotic agent Low level Residential carel High level Residential care Is there evidence that a care plan outlining post Home with supports discharge care in the community was developed Home without supports with the team and the patient and or family if Transitional care services patient has severe aphasia or cognitive impairments Died in hospital
12. Information page will be displayed showing all information entered for the patient Figure 9 5 AuSCR Queensland Hospital User Version 2 0 24 07 2013 17 Figure 9 5 Patient Contacts Section Contacts Emergency Contact Please Select v Title First Name Last Name Phone Number Mobile Number Please Select Relationship Sameas patient home address above Home Address Type Street Address Select v Suburb State Postcode Please Select Country Alternate Contact Please Select v Title First Name Last Name Phone Number Mobile Number Please Select Relationship Sameas patient home address above Home Address Type Street Address Select v Suburb State Postcode Please Select v Country GP Contact First Name Last Name Phone Number Mobile Number Street Address Select v Suburb State Postcode Please Select Country AuSCR Queensland Hospital User Version 2 0 24 07 2013 18 10 Adding a New Episode The AuSCR Database requires that clinical information for the current admission is recorded as a separate episode of care Patients may have multiple admissions for stroke or have a stroke while in hospital for another condition A new episode should be created for every new admission for stroke experienced by the patient If a patient has already been recorded in the AUSCR database you will be made aware of this once you have entered their details refer to Section 11 Adding a New Patient
13. JC JC Cd Phone Number JL JL JLJE ILLE L Mebite Number LE E E COE LUE HL LJ Relationship to participant l lelleteltsi t JT L3 J JL JL JL IL Alternate Contact First Name JE E JE JE E Y JEU E JEJE CY JE JC C30 JE JC JC JC JC JC JE 1C 3 CJ Last Name JE TE JE JEJE JE JC TC JE JE 3E ECC C JC JC JC JC JC JC JE JC JC JE JCJC3 Address type Home T Business Other Street Address J J D JE Y JE JE JEJE JC JE JC JC JC JC 4L JE JC JC JC JC JE JC JC JC JCJ Suburb LJEJEE JEJE EIC YE JE C 3E JC C JC oOo Post Code OOOO State LJEJCIEJEJCIEUE Country LJE 3E 3E JEJE 3C JE JE OOOO Phone Number JEJE JEJE JC JE IE JLUL J Mobile Number LJEJXEJXECHE EC HLUE E Relationship to participant L JEJECJEJEJC IE JCIE JE JEJE JEJE C General Practitioner ePFistName JL JL JE JC YE JE YE JEJE Y JC JC JC JC JC CC JC JC JC JE JC JC 3C 103 SPLastName JL JL JE JE JEJE JE JC JE JCJCYCOCC JE JC TC 3C JC JE JCJC E 3C JC 103 SeetAddress JL JL JL JE JE 3C E JE JEJE EC E JC JC JC JC JE JCJC JC JC JC JE JCJEC 3C Suburb LJEJEJE JEJE JC Y JE JE JC JE JC JC JC C IE 3C JC JC JC JC JC C301 Post Code LJEJE E EE JE 1E state JE JE JE JE CE JC Couniry LJL 3E JE E JEJE JE JC YE JEJE JEJE CIC E JE C 30303 GP Telephone Number EL JEJE JEJCIEIEJCIE UL GP Fax Number EJE E 3E JEJE ACE YE 3E AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 QLD Form SA6 v2 AuSCR Queensland Hospital User Version 2 0
14. Patient button on the navigation menu and the New Patient page will be displayed Figure 9 1 Type the patient s First Name Last Name and Date of Birth into the appropriate text boxes Type in the patient s Medicare Number if known Do not enter DVA numbers Please check all details against the medical record before saving Once saved a Patient ID link within the database will be created and cannot be changed Once the details have been checked click the Save button to save the new patient s personal information or click the Cancel button if you do not want to add a new patient Once the new patient has been saved a Patient Record page will be displayed Figure 9 2 Figure 9 1 New Patient Page A p a H Welcome Steven Australian Stroke Clinical Registry Administration New Patient User Account Download paper based hospital data form Patient a Download paper based QLD hospital data form New Patient Personal Information Search Patient Follow Up z Homer First Name Report B Doh Last Name Data 01 04 1970 Date of Birth 1234 45678 9 Medicare Number Goldcosst v Hospital required AuSCR Queensland Hospital User Version 2 0 24 07 2013 13 Important notes e The patient s name date of birth and Medicare number cannot be edited once saved If an error is made in these fields the incorrect New Patient must be deleted and a New Patient must be created with the correc
15. Refer to the AUSCR Data Dictionary for definitions explanation and help notes on all the variables required to be entered in the database To add a new episode e Click the New Episode button at the bottom of the patient Information page and the Episode page will be displayed allowing for the entry of Admission Clinical Discharge and Death Information Admission Information Figure 10 1 If the patient was transferred from another hospital or has a stroke while in hospital refer to the AUSCR Data Dictionary for correct date and time entries for the different scenarios of admission information This will ensure consistency 1 Enter the following Admission Information and indicate whether each date or time is Accurate or an Estimate by clicking one of the corresponding radio buttons e Date of arrival to Emergency Department Type a date using DD MM YYYY format or use the embedded calendar next to the date box to permit auto completion of date e Time of arrival to Emergency Department ED Enter the time which has been electronically generated on the emergency face sheet for the patient s arrival at the hospital ED If this time is not available use written documentation by nursing or ambulance staff If there is conflicting data use the earliest time recorded The format used for time is always the 24 hour clock with a colon automatically inserted to separate hours and minutes hh mm e Onset of stroke date Type a date usin
16. X JC JC XJ CLIE 1L Post Code 2E DESE2CYEC JC EJ state MS JE IX 4C Country IA Toy srmperAerAW Jc YXC X XC CC ICE CECI Phone Number LIT Y Y JC JC ILL wes e Number OAZEAGOTMAAH Relationship to participa BIER Y LC JL JC C JL General Practitioner cPristName CARRYODOOCOOO0OOOOOJOOOCOQOOOO GP LastName BlorojtCIP els T Y Y ECCE IDJC JC XC JC JC CC JIOECQIOEC 13 SueetAd ress 31 21 J rejriterei Tire enel X C c X Y C JC 173 Suburb ste I CDpr EE CT AT y C YE CIC ICE DC JCDIECXOC IDE III Post Code lans CY Y 31 State EI EDI E Y Y 101 Country Tto sir eae ACC Y EC COE CC ICE JC GP Telephone Number OES zy e rstsistsr GP Fax Number LICUIT m AuSCR Queensland Hospital User Version 2 0 24 07 2013 60 y Patient Name Retty Pobble DOB C1 OY4 197 Hospital Pave 2 o Vo e ZERA ommy Accurate D Estimate lo Iz les 24 hour clock XY Accurate L1 Estimate E Je vele VEZ le M C2 casimmiyyyyy C1 Accurate lo lle 24 hour clock C Accurate L AE timate ZIE Mele VEZ f IE commn euste E Estimate eva 24 hour clock v curate Ej Estimate Admission information Date of arrival at Emergency Department Time of arrival at Emergency Department Date of stroke onset Time of stroke onset Date of admission Time of admission Was the patient transferred from another hospital Did this stroke occur while the patient was in hospital Is there do
17. been registered as a Hospital User user with AuSCR Username hospuser Password testing1 You can change your password when you next log in For further enquiries AuSCR contact details are listed below AuSCR Project Coordinator Phone 02 9993 4592 Email admin auscr com au Website http uatsmsmt demo com 80 auscr How to Change your Password To change your password 1 2 D E CE Click the User Account button on the navigation menu Click the Reset Password button on the navigation menu and the Reset Password page will be displayed Figure 6 1 Type your current password in the Current Password text box Type your new password in the New Password text box Re type your new password in the Confirm New Password text box Click the Update button to save your new password or click the Cancel button if you do not want to change your password AuSCR Queensland Hospital User Version 2 0 24 07 2013 9 Figure 6 1 Reset Password Page AUSCR Australian Stroke Clinical Registry Home User Account a Reset Password Patient New Patient mame pas required Important note If you forget your password email the AUSCR office admin auscr com au stating that you have forgotten your password and include e First name and Last name e Role in AuSCR e g Hospital User e Hospital name A new password will be emailed to you 7 Logging In Once you have obtained your username a
18. in the web tool You should also make sure that Date of discharge is the same as Date of death What do do for people who go home and were not given an information sheet It may be that a person has been admitted and discharged without receiving an information sheet It is imperative that everyone receives an information sheet therefore patients must be contacted by letter following hospital discharge by their treating doctor to provide them with a copy of the Participant Information Sheet A sample copy of a Post Discharge letter is attached in Attachment 6 AuSCR Queensland Hospital User Version 2 0 24 07 2013 49 Appendix 1 Technical Specifications for Import File Data Entry Data Source The data are commonly sourced from the local Health Information System HIS A query is used to extract a cohort of patients with stroke based on diagnostic codes This candidate list may also contain non stroke patients and may also miss stroke patients If necessary the clinician should remove the inappropriate entries from the list and add the missing patient details This needs to be formatted according to the following rules Saved on a worksheet in an Excel spreadsheet file A template is available from the AUSCR Database by clicking the link in the main menu Data Import Excel Then click the information button and click the hyperlink Download the template with sample data here The name of the worksheet is mandatory Data Impo
19. mm yyyy Gender Male Z1 Female Country of birth Alls Jer Mte re A 0 1C JC 10 JE 3C JE JE E JC 1 Language spoken teres SH JC E CL JCICIOGICIC ETE 1C interpreter needed E Yes V o Is the patient of Aboriginal and or Torres Strait Aboriginal but not Torres Strait Islander origin islander origin Torres Strait Islander but not Aboriginal origin L Both Aboriginal and Torres Strait Islander origin Neither Aboriginal nor Torres Strait Islander origin AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 OLD Form SA6 v2 AuSCR Queensland Hospital User Version 2 0 24 07 2013 59 Patient Name Bety Robble DOB Ol Off 1971 Hospital Rove Tgneous rine BIBTEX EY ECT YT EETETITITTEE Last Name TOTIS Y CECI IDE EE EX IDEE EET Address type W Heme Business C Other Street Address MIR elfe z y ar reparare JE Jc 3c CC Jc 3C JC CC 103 Suburb Sy eJ mp Cte ET Ae 1L XC XC EC IAE JEJE CE YCOC ICI CI PostCode AZ gs IOI sate JL DE Y JL E LJ Country ATO SC LOCARE AE X 7 C CC CIC XC JC JC Phone Number OAGAAONAGE MobeNumser OOOOOODOOO Relationship to participant SJPIT2Xo ESIKEE JE JE JC JL ILE 1C Alternate Contact First Name DILCIN JE C YE C Y JEJE EE JC JC JC EC JC JEJE JC JCJL JC JC Y YE Last Name E fed E JE JC Y Y Y C IDJC 3C JE JEJE ECC JC JC JC C QCIC Address type Home Business Li Other Street Address 2 feu Fan Jerem JL JC JEJC JC E JC JC 103 Suburb Ile YAE E Te TAE a C y Y
20. sheet your hospital approved version Attachment 1 AuSCR Queensland Hospital User Version 2 0 25 10 2013 4 4 If a patient requires an interpreter to understand medical information AuSCR recommends that an interpreter be used to explain the information in line with your usual hospital practices For those patients aged under 18 years or those unable to understand the opt out consent processes the information sheet should be given to the parent guardian or next of kin It is important to clarify that the patient guardian or next of kin may request to remove or opt out any information at any time and that this right does not end on discharge from hospital and will not affect their care If a patient their parent guardian or next of kin asks to opt out of the Registry they can do so by contacting the AuSCR office by telephone or email as described in the information sheet They may also sign the opt out form Attachment 2 When hospital staff are advised that the patient or their next of kin would like to opt out of AuSCR it is important to clarify which variables they would like removed it is possible to keep only details about their stroke in the database while still removing all personal and identifiable information about the patient The signing of the opt out form Attachment 2 ensures that a record of the patient s request to remove variables from the AuSCR Database remains on their medical file for all future admi
21. then you should Delete this case and not request this person to be Opted out If a patient is happy to have their details in the AuSCR Database but does not want to be contacted again at follow up post discharge you should only then click the Do not Contact Patient at Follow Up box which appears beneath the discharge information screen This is not a request for this person to be Opted out Important notes The actual opt out can only be performed by a Superuser or the Data Manager Opt out cannot be reversed once it is confirmed Please re read the Opt out Consent Model in Section 3 before proceeding with an opt out request AuSCR Queensland Hospital User Version 2 0 24 07 2013 34 Figure 15 1 Opt out Page Select AT Do not contact for follow up Li First Name T Last Name T Date of Birth Medicare No Ir Title a Gender LI Phone Number r Mobile Number E ne LI Country of Birth Ir Language Spoken Ir Interpreter Needed Address Mailing Address a E vro EO Address Suburb Address State Address Postcode Address Country Contacts Last cContacts Phone Contacts Mobile En Contacts First Name mds uem in IF Contacts Relationship Contacts Address Type Contacts Address Contacts Suburb Contacts State Ir Contacts Postcode Ir Contacts Country Date of arrival to emergency Time ofarrivalto Onset of stroke Onset of stroke T Date of admission to d
22. 013 37 Completing the Queensland Acute Data Collection Form Write neatly and legibly with black ink Write Patient Name Date of Birth and Hospital name or place a Bradma patient ID sticker at the top of each page of the form this will ensure that the record remains intact even if pages get separated All patient information details must be completed with as much information as you can obtain This is to assist in follow up of the patient at 3 6 months Mandatory questions are marked with an asterisk These questions must be completed If the information is not available write the reason next to the question e g to be obtained later not available With estimated or unspecified times and dates use the rules for estimating times and dates that are outlined in the data dictionary If you are using the hospital label and the name of the hospital is not printed on the label please ensure your Hospital Name is entered in the box provided Some hospital labels do not indicate Medicare numbers MRN or DOB next to the numbers If this is the case please complete the MRN and DOB box on the form Correction of errors If an error is made when completing the form please cross out using a single line place the correct information next to or above the correction initial and date the change Do not use whiteout Storage of completed Queensland Acute Data Collection forms Completed Queensland Acute Data collections for
23. 2 14 Request Deletion of a Patient Record eese 32 15 Request to Opt out Data from AUSCR eene 33 16 AuSCR Queensland Acute Data Collection Form essss 36 17 Downloadable Reports of summary data eeeeeeeeeeeeneenen 39 18 Data Export Function Hospital Administrator Only 42 19 importing Dal ooi erret 44 21 zum M 45 22 Error Sereg S aaa rues e Dc aAa AAAA ap ves duc Aan d Deci ves d UG rbka el Loris dS rEERE Lc 46 23 Quality Assurance Data Management Processes eene 47 24 i p rr Sepp M 47 25 Frequently Asked Questions cesses eeeeeeeeee ee eee nennen 47 Appendix 1 Technical Specifications for Import File Data Entry 50 Attachment 1 Example of Patient Information Sheet eesssss 52 Attachment 2 Example of Opt out Request eee 54 Attachment 3a Example of Correctly Completed Acute Data Collection Form 59 Attachment 3b Example of Poorly Completed Acute Data Collection Form 63 Attachment 4 Data Dictionary provided to your Hospital eesssss 67 Attachment 5 Example of User Request Form scccccccssseeeee
24. 2011 End date 31 12 2011 3 4 isl Hospital s 12 sos asa ara e o aef 170 s23 1222 465 0 a o ol a ee r ee Ye i 163 50 8 152 47 4 8 7 al zal id 73 A 8 4 16 Date report generated 24 Oct 2013 7 18 DISCLAIMER Please note the data given in this report have not been verified or checked by the AuSCR Management Team and are for internal information only 19 Swallow screen prior to oral intake 100 WSelected hospital s BAI State l Sos e 4 y Ss S 48 og a Su AuSCR Queensland Hospital User Version 2 0 24 07 2013 41 18 Data Export Function Hospital Administrator Only The AuSCR Database has a data export function This function allows for the export of raw data directly entered from your hospital for the date range selected The raw data are provided in an Excel spreadsheet and can be manipulated for internal hospital reporting as desired Outside of the date ranges for which the AuSCR office has verified the data it is your hospital s responsibility to check and clean the raw data Important notes All data exports must be saved securely with a password o spreadsheets with identifying information deleted To export data 1 Click the Export Excel button on the navigation menu on A C nm N Click the Data button on the navigation menu The Export Excel Data screen will
25. AUSCE Australian Stroke Clinical Registry Hospital User Manual Queensland sites October 2013 Version 2 0 AuSCR contact details AuSCR Project Coordinator Email admin auscr com au Telephone 03 9035 7264 Secure fax 03 8888 4990 Mail AuSCR Office Public Health The Florey Institute of Neuroscience and Mental Health 245 Burgundy St Heidelberg VIC 3084 Website http www auscr com au Table of Contents 1 Doc me t OVGIVIOW WT 4 2 Background Infotmallon 5 teed ee eee eee 4 3 The Opt Out Consent Model ccccceeseseeeeeeeeeeeeeeeeeneeeeeeeeeeeeeeesesseeneeeeeeeeesensees 4 4 General Information about the AUSCR Database eene 5 5 How to Obtain a Password retener retten tinet nennen neueren 7 6 How to Change your Password eese nennen nennen nnns 9 7 Logging mtt 10 8 Navigation e 12 9 Adding a New Patleni 2 n erreidet ce edet asi ndece ccrtc etus spada lectern 13 10 Adding a New Episode eeeeeeeeeeeeeeeeeeeeeeeeee eene eene nntnn nnn n ranas nean nn 19 11 Searching for a Patient or to Edit Patient Data eese 30 12 Locking an Episode o rone eandem phia neuter Ra Ianue ERR 31 13 Request Deletion of an Episode eeeeeeeeeeeeeeeeeeeennnnnn nnne 3
26. D My mobile number L Names of my Next of Kin and or Altemate Contacts C Telephone numbers s of my Next of Kin and or C Address s of my Next of Kin and or Alternate Contacts Altemate Contacts O Nameoft my GP O GP address DL GP Telephone number D Ai of my personal information Information about my stroke and care received in hospital D Date of the onset of the stroke D Time of the onset of the stroke O Date of arrival to Emergency Department Ll Time of arrival to Emergency Department Ll Date of admission to hospital O Time of admission to hospital o Whether or not this was your first stroke o Whether you were transferred from another hospital o Whether you were able to walk when you were o Whether the stroke occurred while you were in hospital admitted to hospital o If you were treated in a Stroke Unit o Type of stroke D you were mobilised during admission o If you received swallowing assessments D tt you were given aspirin within 48 hours o Hospital codes that define your diagnosis medical condition and any complications or procedures o If you were given a care plan at discharge o Date of discharge from hospital D r you received an Antihypertensive agent at o If you received antiplatelet antithrombotic medication discharge at discharge Ll Discharge destination Ll Date of death if applicable C Ait of my stroke and hospital care information o Being contacted and having follow up details recorded in the Stroke Registry eg support services w
27. E JEJE YE YE C Y YE 1E 1E E YE 1E 1 LJEJ JE YE EYE YE EC JEJE E E JE YE YE EYE YE E E E E E EE E E 1 OOOOOOOIOO sse OO00000 00 L JE JEJE YE JEJE YE E YE YE E E JE YE YE JE YE YE E Phone Number J J JL JL Motite Number LE 1E E E EC E E YE 3E Medicae No JL JL IL IL IL IL E IE JE espta mans C YL Y JE YE E JE E JE E DaeotBit IC ILIVLILILILI yy Gender _ Male Femae country efbith E IL JE E E JE E YE YE JL E E EYE JE YE E YE YE 1E 1 Language spoken IL IL TL JL JL JE E YE JC E E EYE JE YE E 3E YE 1E 1 Interpreter needed ves _ No Is the patient of Aboriginal and or Torres Strait Aboriginal but not Torres Strait Islander origin iin Strait Islander but not Aboriginal Sud L Both Aboriginal and Torres Strait Islander origin L Neither Aboriginal nor Torres Strait Islander origin AuSCR AcuteData CollectionF omm Queensland V4 28October2013 Clean docx AuSCR Queensland Hospital User Version 2 0 24 07 2013 55 Patient Name DOB Il Hospital Emergency Contact FirstName JL JL YE E 3E YE YE 3E YE YE EE EYE EYE YE YE YE EYE E E 1L E TL Last Name JL E JE E 3E 1E E 3E YE YE E YE YE E 3E YE E E E 1E E E EYE YE EIE Address type L Home O Business 0O Other Steet Address D T J 1L Y Y E E Y E Y Y JE Y YE IE Y ET Y T TE Suburb LE Y YE YE Y 3E YE YE YE YE 3E YE EYE YE YE JEIE E JEJE TE YE YE E Pescode JL IL IE E JE E 1E sse OO0OOOOOC Country LJE Y Y YE YE Y 3E YE YE EYE YE Y E 3E YE
28. HOOD O0O00O 0O00 0000 Was the patient mobilised in this admission Yes O No Lj Unknown Date of first documented mobilisation an lolle V2 Yel Y2 aammyyyy Accur rate Estimate Method of first mobilisation Sitting Standing walking Assisting the patient upright and out of bed this includes Please select the one method documented within the sitting over the edge of the bed medical record Dysphagia Screen Tool used ET Yes L1 No Was screening or assessment of swallow conducted prior 2f ON to any giving oral intake medication food fluids es e Screen Result Norma Abnormal el ccurate 7 Estimate Time of Screenin f g lo Als 24 hour clock accurate C Estmaie Formal Speech Pathologist Swallow Assessment Iv Yes O No Date of Assessment St Sur Ae ummy urate Estimate Ti f A me ot Assessment HE anon clock Accurate W etmate Aspirin given within 48 hours ai LJ No O unknown Date of Commencement ub Viele Vile 2 dd mnvyyyy AuSCR ACUTE DATA COLLECTION FORM V3 i 17082010 QLD Form SA6 v2 3 Date of Screening AuSCR Queensland Hospital User Version 2 0 24 07 2013 65 Patient Name Betly PA 3bb le DOB 21 OH 19 7 Hospital Eoyol a Tar Ha Accurate O Estimate Hine oF Commencement lo le ele 24 hour clock C Accurate EJ stimate Separation Discharge Information Patient Deceased V No Yes date of death 1 VE JL VL 1E JL JL id mevyyyy
29. If the Type of Stroke selected is Ischaemic the following question will appear If an Ischaemic stroke did the patient receive intravenous Thrombolysis tPA Please select from the drop down box Yes No or Unknown AuSCR Queensland Hospital User Version 2 0 24 07 2013 22 Cause of Stroke To ensure a systematic and consistent approach to defining known Causes of Stroke the TOAST classification system is used For further information please refer to the AuSCR Queensland Data Dictionary The modified TOAST criteria should be applied to determine if the Cause of Stroke is Known or Unknown Table 10 3 TOAST classification Cause would be Known if Cause would be Unknown if e Large artery atherosclerosis e Stroke is of undetermined etiology i e e Cardio embolism cause cannot be identified e Small vessel occlusion e Two potential causes are present but it is e Stroke of other determined etiology unknown which is likely to be the cause illicit drug use e Evaluation is incomplete metabolic disorder intervention post operative Important note ICD10 codes may not be available until after the patient is discharged These codes can be entered later Please complete all other data AuSCR office will send a regular reminder for the data missing from these fields ICD Codes 1 ICD10 Principal Diagnosis Select a stroke ICD10 code from the Principal Diagnosis drop down list If
30. J First Name Last Name Post Code LL TEE E YE JE ste CE E JC JE C JC C1 Country LJE JE YE EYE EE E JC JE CE JC JC HC JC JC JC JC EJ Phone Number J JL JL JL JL JC IL ID Mobien LL L JL 37 JEJE Medicare No L JEJE OE EE JE JC respi mans CAEJE JE CIC JE JCJC JL Date of Birth lel veu E eamuyyy Gender Male _ Femate Country ofbirh JE JE JD JE JE JE JC JE JC C C JC JE CC JL JC JC CC d Language spoken J E JL JE Y JE 1E 1L 1 3E JC JE JC JL LC JC CC JE J Interpreter needed EJ Yes No Is the patient of Aboriginal and or Torres Strait _ Aboriginal but not Torres Strait Islander origin Islander origin C Torres Strait Islander but not Aboriginal origin L Both Aboriginal and Torres Strait Islander origin L Neither Aboriginal nor Torres Strait Islander origin AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 _ QLD Form SA6 v2 AuSCR Queensland Hospital User Version 2 0 24 07 2013 63 Patient Name DOB ospital Te AE t Emergency Contact FirstName B JV ote IE JE Y JC JC JE E C JE JC JC JE JC JC JC JE C JC JE JC JE 10 JCJ LastName Rolga E C YE E YE JC E CTC OCC OE JC JC JC JC JC JC JE JCJC 1E Address type Home lBusiness _ other Street Address 1 2 SHAE YA dE 1L JC JE JC JL JE JE JC JE EC JCJE JE Suburb BAREA A Ea e E JC JC JC JC JC JEJE JE JE JC JC ICIECJCICI Post Code Kiss JOO state ExlLJSE C YE C 3E Country LAJEoIFS EC esL EE LAC TE EC XC JC JE JC JC TE
31. National Stroke Foundation and the Stroke Society of Australasia It has been approved by the Human Research Ethics Committee at local hospital The Stroke Registry database has been specially designed to ensure that your privacy is maintained All information about you and your stroke is treated as strictly confidential Neither your identity or personal details will be revealed in any publications or made available to outside organisations Participation 1s voluntary and to take part in the Stroke Registry you do not have to do anything the hospital will automatically enter details about your stroke into the database If you would prefer to have some or all of your details removed from the database please carefully read the Information Sheet and then contact the AuSCR Project Office and let them know what information you would like to have removed It is possible to remove only some of your information such as name and address and keep information about your stroke and your hospital treatment in the database It is also possible to request that you are not contacted again that 15 at 3 6 months after your stroke and to still keep important medical details about your stroke provided by the hospital into the database If you wish to contact the AuSCR Project Office about removing some or all of your information from the Stroke Registry by telephone on 1800 673 053 email admin auscr com au or by mailing the enclosed opt out form to Public Heal
32. O Accurate 1 Estimate Discharged Alive a Date of discharge Pede darmmyyyyy ecurato D Estimate b Discharge CJ Transfer to other hospitai J Home with support destination mode acute L Home without support L1 SNAP still in hospital O Transitional care services Rehabilitation Inpatient Died in hospital L Low level Residential Care C Other C High level Residential Care c Discharged with antihypertensive agents I es C No J Unknown a Discharged with antiplatetet antithrombotic Yes I No CI Unknown b is there evidence that a care plan outlining post discharge care in the Ys O No community was developed with the team and the patient and or family if patient has severe phas or cognitive impairments O Not applicable Unknown Opt Out Request Place v in appropriate boxes Medical information Personal information O Do not wish to be contacted for follow up Form completed by LJ JI Y 1 3E ICE EC JC 3E JE IC JC E ELE CIL JE CC Date LIE MEJCVC ETE ILUA Contact Number LJELJE CJCOE CILE IE AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 _ QLD Form SA6 v2 4 AuSCR Queensland Hospital User Version 2 0 24 07 2013 66 Attachment 4 Data Dictionary provided to your Hospital The data dictionary is also available on the AuSCR website at http www auscr com au health professionals forms manuals data dictionaries AuSCR Queensland Hospital User Version 2 0 24
33. SSIONALS Find information on the benefits of AUSCR to health professionals Learn how your hospital can participate in AuSCR read more Home RESEARCH Learn about the many benefits of AuSCR for researchers You will also find links to Research Publications and Proposal submission guidelines read more AUSCR Find out about AUSCR our governance structure and sponsors Read through our FAQ section and browse our Policy Documents and Reports read more O The Australian Stroke Clinical Registry AuSCR is a collaborative national effort to monitor promote and improve the quality of acute stroke care We believe that by working together patients families clinicians and researchers can make a difference in the lives of people affected by stroke July 23rd 2013 July 2013 Newsletter load AUSCR July 2013 Ne Media Release The data collected will guide quality improvement interventions in hospitals reduce variations in care delivery and ultimately provide evidence of reduced deaths disability and recurrent stroke The Australian Stroke Clinical Registry will ensure best practice stroke care in Australia Download Brochure Registry Login The Australian Stroke Clinical Registry collects data from participating hospitals CLICK HERE across Australia using an online web tool Hospitals can use the online tool to store their own patients data 1 i Consortium Partner AN 72 NE e provide clinici
34. Y EIE T Phone Number JLJLILILILILILILIL Motienumber I E JE 1E E E IE 1L E Relationship to participant JL JLJL 3L E JE E 3E 3E JE 3E 1E 1E FirstName LJ TE JE JEJE E EYE JE E JE YE JEJE YE E E EE E JE YE JE E JE YE 1 Last Name LJ JL TE E E E E JE EYE EE JEJE EL E EC YE EC YE C YE CIE E 1E Address type Home Busimess Other Steet Address Ll OI JL JE JE E JE 3E 3E JEJE E JC YE JE JE 3E E JE JC YE IE E CE 1 Suburb LJ JEJE YE YE JE E EE JC YE E YE EE E AE E E JE YE E E JE TE TE 1 JEJE YE JE IET sse E EE T YE EY Country LJ JEJE E E EYE E EET E JE YE JE E EE TE 1E Phone Number IL IL IL JL IE IL ILL esie Number E EL E JE E EL IE YE 1E Relationship to participat JL IL ILJL JL JE JEJE LE JC YE IL 1L LY Y JE Y Y JE T JETE T JE T JEU TE JE T EET OOOO LI JE T Y JE Y YET T E JETE TE JEJE T JE T JCIETE T LJ JE Y Y Y EYE YE YE YE E E JE YE E JEJE Y YE JE YE Y JEJE YE T LI JE Y Y T ET state JL T LT LY JE Y Y Y YE Y YET E Y JE Y Y JEJE 1E GP Telephone Number L 1 JL 1 Y 1L 1L GP Fax Number OOOO AuSCR AcuteData CollectionForm Queensland V4 2 SOctober2013 Clean docx 24 AuSCR Queensland Hospital User Version 2 0 24 07 2013 56 Patient Name DOB Hospital Date of arrival at Emergency Department LILICILYLEILILIE scmevyyyy C Accurate Estimate Time of arrival at Emergency Department _ _ rou cioc O Accurate C1 estimate Date of siroke onse
35. YY format or use the embedded calendar next to the date box to permit auto completion of dates Please indicate whether this date is accurate or an estimate by clicking on the appropriate radio button Time of screening Select the time using the 24 hour clock format hh mm Please indicate whether this time is accurate or an estimate by clicking on the appropriate radio button Figure 10 5 Swallow screen or swallow assessment prior to oral intake Was screening or assessment of swallow conducted prior to any giving oral intake medication food fluids Abnormal Screen result 24 10 2012 Date of screening Q Accurate C Estimate 14 00 Time of screening hh mm 24hr clock Q Accurate C Estimate AuSCR Queensland Hospital User Version 2 0 24 07 2013 25 Formal Speech Pathologist swallow assessment Figure 10 6 A Speech Pathologist has a specialised body of knowledge and is responsible for comprehensive assessment and management plans of patients with identified dysphagia For further information please refer to the AUSCR Queensland Data Dictionary Please select from the drop down box Yes No or Unknown If the answer is Yes this will expand the section to display additional data entry fields Date of screening Select a date using DD MM YYYY format or use the embedded calendar next to the date box to permit auto completion of dates Please indicate whether this date is accurate or an e
36. anaging known as follow up Pulunt NNI eI Poder p Un PEUT DUDEN E NEM EUOQU CHINE Date of Birth Phone Mobile contact ee eere eee eene nennen nnn Signature of Patient or Authorized Proxy eene eere nnn nnn DEI nee eee ASEE Qid QLD AuSCR Information Sheet for Patient and Relatives and Consent Final V9 28October2013 Clean doc AuSCR Queensland Hospital User Version 2 0 24 07 2013 Attachment 2 Example of Opt out Request m ra Opt Out Request Queensland AG S B Removing information from the Australian Stroke b JAM MA NAS he Clinical Registry database Australian Stroke Clinical Registry Please send this form to the AuSCR office Hospitals should also retain a copy of this form filed in the hospital medical record to document the patient s decision NOT to join the Stroke Registry have read the Stroke Registry patient information sheet understand the purpose and the benefits of my details and medical records entered into the Stroke Registry also know that have a choice to request exclusion from any section of the Stroke Registry and at anytime Please IZ tick the information that you would like removed from the Stroke Registry Personal information about me O Name D rite Mr Mrs etc L Medicare Number O Gender O Date of Birth Ll Aboriginal Torres Strait Islander status o Country of Birth o Language spoken C My address DL Mytelephone number
37. ans with downloadable reports summarising their patients s data E Click allow hospitals to export their data for local analyses and e provide annual performance reviews newsletters and publications here To access the Australian Stroke Clinical Registry you need to be a registered participating hospital with approved log in access Please contact admin auscr com au to enquire about participating If you are a registered participating hospital please use the REGISTRY LOGIN Figure 7 2 Login Page AUSCE Australian Stroke Clinical Registry Username Password Forgot yourjuser name and or password Please email admin auscr com au See Note under point 5 AuSCR Queensland Hospital User Version 2 0 24 07 2013 11 8 Navigation Menu Once you have logged in the AUSCR Database Home page will appear with the navigation menu displayed on the right hand side Figure 8 1 The navigation menu then appears on each page while you are logged in Table 8 1 briefly describes the features of the navigation menu The word Home also appears in a blue bar at the top of each page under the AUSCR logo Clicking the word Home will take you back to the Home page Figure 8 1 Navigation Menu AU X Br v 4 H Welcome Hospital Australian Stroke Clinical Registry User Account M Welcome hospuser ms Patient e New Patient Search Patient Welcome to the Australian Stroke Clinical Registry The Australian St
38. are representative of all strokes in your hospital it is important that particular attention is given to ensuring that complete data are collected on all patients and that all eligible patients with stroke and transient ischaemic attack TIA are included in the AuSCR Database If an incomplete set of patients is collected from a hospital then biases in the data may occur and the usefulness of the data will be limited To ensure as complete a set of patients as possible from each hospital AuSCR uses an opt out consent model with a waiver of consent for those who die in hospital This means that all patients admitted with stroke or TIA at your hospital should be entered in the AuSCR Database unless they their parent guardian or next of kin formally requests not to be included on the registry All patients who die in hospital should be entered and families next of kin do not need to be informed of this data entry To ensure informed consent that is in line with the ethics approval it is the responsibility of the participating hospital to provide the approved AuSCR Information Sheet to all patients admitted with stroke and TIA This information sheet clearly explains the purpose of AuSCR and how patients may opt to have some or all of their data removed from the AuSCR Database In general the process for providing this information to patients within your hospital should be e All patients or their relatives are provided with the AuSCR information
39. are will also be collected How will we keep your information confidential All personal information is kept strictly confidential and cannot be used outside the Registry Information is stored in a specially designed password protected database which can only be accessed by a small number of approved Stroke Registry staff Qld QLD AuSCR Information Sheet for Patient and Relatives and Consent Final V9 28October2013 Clean doc AuSCR Queensland Hospital User Version 2 0 24 07 2013 xa eT Once your information is entered into the registry it will be given a unique identification number for analysis This means that your name will not be identified in any reports that are produced and your privacy and confidentiality will be maintained How will your information be used and reported Your information is protected and we are not allowed to identify you by law The Stroke Registry will produce reports on factors that influence the success of stroke care and rehabilitation aspects of such reports may be presented at conferences or submitted for publication in medical journals It will not be possible to identify any individuals in any reports To maintain absolute security and confidentiality anyone wanting to use any of the data from the Registry will be required to obtain ethics approval from an Ethics Committee What are the risks and benefits to you There are no risks to your health by having your details stored in the Stroke Registry
40. aring settings For this workbook Password to modify l 1 1 7 Read only recommended Digital Signatures Privacy options Remove personal information from this file on save Macro security Adjust the security level For files that might contain macro viruses and Macro Security specify names of trusted macro developers 4 This will open the Encryption Type dialogue box AuSCR Queensland Hospital User Version 2 0 24 07 2013 44 5 Select RC4 Microsoft Enhanced Cryptographic Provider v1 0 from the Choose an encryption type list Figure 20 2 Select 128 from the Choose a key length field Ensure that Encrypt document properties is checked Click Ok button On the Options screen enter a strong password see below into the Password to open field 10 Click OK button iom Um Figure 20 2 Encryption type Encryption Type S Choose an encryption type RC4 Microsoft Base Cryptographic Provider 1 0 RC4 Microsoft Base DSS and Diffie Hellman Cryptographic Provider RC4 Microsoft DH Schannel Cryptographic Provider de C iced Cryptographic Provider v1 0 RC4 Microsoft Enhanced DSS and Diffie Hellman Cryptographic Provider RC4 Microsoft Enhanced RSA and AES Cryptographic Provider Prototype RC4 Microsoft RSA SChannel Cryptographic Provider RC4 Microsoft Strong Cryptographic Provider Choose a key length 128 Iv Encrypt doc
41. be displayed see Figure 18 1 Type in or use the calendar to select the date range desired Click the Export button The data will be exported to the email address that you provided to AUSCR when you created your log in A message will come up on the top of the Export Excel Data screen see Figure 18 2 Go to your email and click on the link within the email message 8 Save the file to a folder in your computer The file will include personal identifying information of patients and needs to be password protected on a computer with a directory that also requires password access For instructions on how to set a password for an Excel file please refer to the Encrypting Excel data files section Figure 18 1 Export Excel Data Export Excel Data This process will extract system data into spreadsheet format Please enter a date range below to restrict export data by admission date or leave as blank to export all accessible episode related records From admission date To admission date AuSCR Queensland Hospital User Version 2 0 24 07 2013 42 Figure 18 2 Export Excel Data Message AUVSCE Australian Stroke Clinical Registry The data export will be sent to This might take several minutes Export Excel Data This process will extract system data into spreadsheet format You will then be sent a link in an email to retrieve the generated file Please enter a date range below to restrict export da
42. cumented evidence of a previous stroke i e focal neurological signs persisting for more than 24 hours Able to walk independently on admission i e may include walking aid but without assistance from another person Clinical Information Was the patient treated in a Stroke Unit at an time during their stay D C Haemorrhagic C Undetermined Type of stroke O TIA If an ischaemic stroke did the patient receive intravenous thrombolysis tPA a Cause of stroke Known Leanecos Heap Estimate O Yes 3o E Unknown C Yes a fo L1 Unknown L Yes L No Unknown O Yes Yo J Unknown v Yes No J Unknown C Yes fa No L Unknown Diagnosis JOC Medical condition 1 JL 3 0000 nooo ICD10 codes Complication JL 1L 1E 1 DOO00 DOOo Procedures TL L E 1E TP JEJE 1E JE TEE 0000 Was the patient mobilised in this admission Date of first documented mobilisation Method of first mobilisation Assisting the patient upright and out of bed this includes sitting over the edge of the bed Yes L1 No LI Unknown 2 Lee Vi2 Ye IZ comowyyy Accurate J Estimate Sitting Standing Walking Please select the one method documented within the medical record Dysphagia Screen Tool used Yes O No Was screening or assessment of swallow conducted prior to any giving oral intake medication food fluids a fes Li No Screen Result L Normai Abnormal Date of Scr
43. data were entered not by the date of the stroke admission e Ifthe episode is locked the episode cannot be edited and the Edit button will not appear A request can be made to the AuSCR office to unlock the episode to enable editing of the episode AuSCR Queensland Hospital User Version 2 0 24 07 2013 30 Figure 11 1 Patient Search Page AUSCE Australian Stroke Clinical Registry Search Patient Details First Name Last Name MRN Patient List Name Medicare Number MRN Date of Birth Hospital Status John Smith 1212 121212 111111 01 04 1935 Royal North Shore Active Episode Id Arrive Date Admission Date Stroke Type Status 1 26 05 1994 26 05 1994 Ischaemic Active 12 Locking an Episode The AuSCR Database allows users to lock an episode and therefore prevent it from being edited All episodes must be locked once completed Important notes Do not lock episodes unless ICD10 information is complete and all other data has been cleaned and checked by AuSCR office To lock an episode 1 Search for the patient with the episode to be locked 2 View the episode to be locked by clicking on the hyperlinked Episode ld 3 Click the Complete and Lock button located at the bottom of the page 4 This will change the Completion Status of the episode to COMPLETE and it can no longer be edited Important note Only a Superuser or the Data Manager can unlock a locked i e Complete episode To unlock an episode pleas
44. e contact AuSCR office AuSCR Queensland Hospital User Version 2 0 24 07 2013 31 13 Request Deletion of an Episode All users are able to request the deletion of an episode however this action needs to be confirmed by a Superuser or the Data Manager from AuSCR office before the record is actually deleted To request the deletion of an episode 1 Search for the patient with the episode to be deleted in the Search Screen using the Patient list 2 View the episode to be deleted by clicking on the hyperlinked Episode ID 3 Click the Delete button located at the bottom of the page 4 This will change the Activity Status of the episode to INACTIVE and it will no longer be able to be edited and used by Hospital Users or Hospital Administrators 5 The patient episode requested for deletion will automatically be added to the Delete Episode List This list is only accessible to Superusers and the Data Manager from AuSCR office 6 The Superuser or the Data Manager from AuSCR office will perform the actual deletion using the Delete Episode List during scheduled data management processes Important note Actual deletion can only be performed by a Superuser or the Data Manager from AuSCR office Once deleted it cannot be reversed 14 Request Deletion of a Patient Record All users are able to request the deletion of a patient record however this action needs to be confirmed by a Superuser or the Data Manager bef
45. e drop down list Type in or use the calendar to select the Start Date for the report Type in or use the calendar to select the End Date for the report Click the Generate Report button Oo oF A C A dialogue box will open with an option to open or save the chosen Report Figure 17 2 8 Open option will open the chosen Report for viewing and saving can be done later 9 Save option will allow you to save the chosen Report to a folder in your computer Important notes If there is an error a new error window will appear Close the new error window and go back to the original window to correct your errors AuSCR Queensland Hospital User Version 2 0 24 07 2013 39 Table 17 1 Reports Table Pre Specified Reports Available Patient Episode Totals Characteristic of Patients Age group Profiles Summary Age Data Destination on Discharge Summary of Discharge data Length of Stay Processes of Hospital Care Patients treated in a stroke unit at anytime during stay Patients transferred from another hospital Strokes that occurred while patients were in hospital Number of patient episodes with ischaemic stroke that received tPA Stroke Type by Age Stroke Type by Gender Patients per Month Queensland Process of Care Variables Summary Aspirin administrated within 48 hours if an ischaemic stroke Patients discharged on antiplatelets or antithrombotics if an ischaemic stroke Swallow scr
46. e the Postcode into the Postcode text box Important note Once the State has been selected only postcodes eligible for that State can be entered 7 Ifitis an overseas address select Overseas for the State and this will allow free text in the Postcode box in order to be able to enter an overseas postcode 8 Select the Country from the drop down list 9 Additional addresses can be added by following steps 1 8 above for each address to be added after clicking the Add button at the bottom of the Address section Figure 9 3 AuSCR Queensland Hospital User Version 2 0 24 07 2013 15 Figure 9 3 Patient Address Section Address Iv Mailing Address Home Address Type 123 George St Street Address Sydney NSW 2000 Suburb State Postcode Australia Country Contacts Important notes Any existing addresses can be edited in the table by clicking directly on the address to be changed altering as necessary and then clicking the Add button Addresses can also be deleted by clicking the Delete link to the right of the corresponding address Once the Delete link is clicked a Warning message will display asking you to confirm that you want to delete the address Click the Yes or No button to confirm or cancel the deletion Figure 9 4 Patient Address Table Address Street Address Row Mailing Type Suburb State Postcode Country 123 George St 4 M Home Sydney NSW v 2000 Delete Australia x
47. ecialist and or nursing staff will complete the form that contains the details from your time in hospital This form includes the following information your telephone and or mobile number complications if any contact details of your next of kin or living arrangements after discharge from health contact person hospital This information is necessary to accurately link a person s hospital stay with any subsequent rehabilitation This information allows us to collect further information regarding your health care needs from other linked hospital and health information systems so we know how well you have recovered No other personal information is included After discharge As a participant of the stroke registry you or your next of kin will be contacted either by telephone or mail at approximately 3 6 months after your discharge from hospital unless a request has been made not to be contacted At this time the following information will be collected your name Medicare number date of birth hospital identification number your country x birth D the hospital your preferred language typeofstroke your address medical treatment and care in hospital yourname support that you have received since date of birth leaving hospital address ff after discharge you need more care current health condition rehabilitation or are admitted back to living arrangements hospital information about your ongoing c
48. eeeeeeeeeeseneeeeeeeeeeeeeeeenneees 68 Attachment 6 Example of Patient Contact Letter Post Discharge 69 1 Document Overview This user manual is designed as a guide for hospital staff to access and enter data into the Australian Stroke Clinical Registry AuSCH an online web based tool referred to as AuSCR Database throughout this document Users are assumed to have a basic level of computer skills and be familiar with browsing the internet After logging into the secure AuSCR Database there are two main steps to enter data 1 each patient must be created New Patient 2 each episode must be recorded Episode Details This manual will guide staff through each of these steps and will explain other user options such as printing reports and importing and exporting your hospital s data to and from the AuSCR Database 2 Background Information A PowerPoint presentation can be accessed electronically by contacting the AuSCR office or by viewing the online version on the website www auscr com au The presentation provides an overview of the AuSCR project and includes information on its purpose governance data collection and the benefits of participating in AuSCR First time users are encouraged to view the presentation prior to accessing the AuSCR database You will also need to have your user id and password set up before being able to access the AuSCR database 3 The Opt Out Consent Model To ensure data
49. een prior to oral intake Time of mobilisation within 1 day of arrival within 2 days of arrival within 3 days of arrival outside 3 days of arrival Queensland Process of Care Variables Monthly Figure 17 1 Reports Page AUSCE Australian Stroke Clinical Registry PEJ Select Report 4 Patient Episode Totals v Report Type e Start Date fim End Date AuSCR Queensland Hospital User Version 2 0 24 07 2013 40 Figure 17 2 Report Dialogue Box Do you want to open or save this file Name patientCharactReport xis Type Microsoft Excel Worksheet From uat smsmt demo com oen J JJ v Aways ask before opening this type of fie While files from the Intemet can be useful some files can potentially harm your computer If you do not trust the source do not open or save this file What s the risk Figure 17 3 Examples of Reports A B EE o E F emm n mmm mom mmi L M 1 Processes of Hospital Care Start date 01 01 2011 End date 31 12 2011 Hospital s 8 Total episodes for the period 12 13 Total episodes for the period 14 15 16 Date report generated 24 Oct 2013 17 18 DISCLAIMER Please note the data given in this report have not been verified or checked by the AuSCR Management Team and are for internal information only 19 1 Patient Characteristics based on admission episodes 2 Start date 01 01
50. eening Time of Screening Formali Speech Pathologist Swallow Assessment Date of Assessment Time of Assessment Aspirin given within 48 hours Date of Commencement AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 _ QLD Form SA6 v2 ZEA VIZ NS 12 comm ACCHS ate Estimate loj Ta s 24 hour clock Rd ccurate O Estimate Yes LI No Melle vll E12 esmesyyp anr O Estimate le Hist 24 hour clock J Accurate amai V Yes CI No J Unknown 2 1 Velle Ve 12 cimma w AuSCR Queensland Hospital User Version 2 0 24 07 2013 61 Accurate O Estimate Tina er Cemsanancemn AE lala 24 hour clock O Accurate Estimate Separation Discharge Information Patient Deceased YNo C Yes date of death JL Y 1E JC JC IC aimovyyyy O Accurate C Estimate Discharged Alive a Date of discharge Benon ioa 7 ee D Estimate b Discharge C Transfer to other hospital C Home with support destination mode acute C Home without support SWAP still in hospital O Transitional care services bilitation Inpatient O Died in hospital Low level Residential Care O Other High level Residential Care c Discharged with antihypertensive agents ves O No C Unknown a Discharged with antiplatelet antithrombotic es O No O Unk b Is there evidence that a care plan outlining post discharge care in the Wes O No community was developed with the team and the patient and o
51. epartment emergency department date time hospital r Was the patient able to walk is there documented evidence of a previous independently on stroke wasthepatient Did this stroke transferred from occur while the patient another hospital was in hospital Was the patient treated in a l Did the patient Stroke Unit at any time during m Type of stroke receive Intravenous Cause of stroke their stay Thrombolysis LL ICD10 code icD10 code ICD10 code r onm e e EDO cida Dagio ae Condon Complications Procedures r Time of admission to hospital Li Was the patient mobilised in Ss m r Definition of time a Dysphagia screen i intinn ns this admission bilisation to first mobilisation tool used T was screening or assessment of swallow conducted prior to any giving Screen Result I Screen Date Screen Time oral intake medication food fluids Formalspeech Pathologist IF i n Ir F EU swallow assessment r Aspirin given within 24 Li Commencement r Commencement hours date time T Date of discharge known T Date of discharge z Discharge 5 MM z destination mode Antihypertensive agent antiplate levanlithrombotic isthere evidence that a care plan outlining post discharge care r Deceased r Date of death AuSCR Queensland Hospital User Version 2 0 24 07 2013 LEN Figure 15 2 Opt ou
52. g the DD MM YYYY format or use the embedded calendar next to the date box to permit auto completion of date e Onset of stroke time The format used for time is always the 24 hour clock with a colon automatically inserted to separate hours and minutes hh mm e Date of admission to hospital Enter the date the patient is electronically admitted to hospital Type a date using DD MM YYYY format or use the embedded calendar next to the date box to permit auto completion of date e Time of admission to hospital Enter the time that the patient was admitted to the hospital The format used for time is always the 24 hour clock with a colon automatically inserted to separate hours and minutes hh mm This time should be listed on the hospital admission front sheet or via electronic records E g HBCIS EDS or the Viewer QH sites If the time has not been recorded use written documentation by the nursing medical or allied health staff to estimate a time AuSCR Queensland Hospital User Version 2 0 24 07 2013 19 Important note If the patient has been transferred from another hospital enter the date that the patient arrived in the ED of the first hospital In some cases the date will not correspond with the date of admission to hospital Take care to record the date of arrival in the ED not the date of admission to the first hospital the two may differ if the patient arrives close to midnight and is actually admitted the following day
53. hich is a national stroke register to collect important information about what happens to people who have had a stroke or a mini stroke called a transient ischaemic attack or TIA The Stroke Registry AuSCR collects information from hospitals about patients with different types of stroke the medical treatments patients receive complications that occur while in hospital and discharge arrangements e g access to rehabilitation Because we missed you or your family member during the recent admission to the hospital with a stroke we are writing to inform you that information about your recent hospital stay and stroke will be included in this national database as well as your contact details People whose information is stored in the Stroke Registry AuSCR are contacted by telephone or mail between 3 to 6 months after their stroke to assess the degree of recovery from stroke and any ongoing or new health problems you may have Information about what happens to people after they leave hospital is important since it will allow health professionals such as doctors to improve the care that patients with stroke receive while in hospital If you are unable to answer these follow up questions yourself it is possible to have family members answer these on your behalf We have enclosed a copy of the AuSCR Patient Information Sheet which we hope you will take the time to read In brief the Stroke Registry is a national initiative that is supported by the
54. ho live with and my quality of life Ll Ait of the above information Patient s Name Name of Hospital Date of birth Phone mobile contact Signature of Patient Authorised proxy Date For more information about the Australian Stroke Clinical Registry please call the AuSCR Project Coordinator on telephone 1800 673 053 or visit our website at www auscr com au Postal Public Health Stroke Division Melbourne Brain Centre 245 Burgundy St Heidelberg VIC 3084 Fax Attention AuSCR 03 88884990 Opt out Form Master V5 Queensland V1 280ctober2013 Clean doc AuSCR Queensland Hospital User Version 2 0 24 07 2013 54 Attachment 3 Example of Acute Data Collection Form DATA COLLECTION FORM AUSCH QUEENSLAND Australian Stroke Clinical Registry Please complete the form For any queries contact the AuSCR office at the Neatly and legibly Florey Institute of Neuroscience and Mental Health Write in black ink and press firmly Each question must be completed Ph 03 9035 7264 Email admin auscr com au Place v in appropriate boxes Required fields marked with must be completed Hospital Name Patient Information Title LJLIL Y JE JE YE YE JE YE EYE FirstName C f f gp JE Y E EY E E EY JY Y YE YE YE EYE JE EYE YE YE JE 1E 1 tatame JC J JE TE E JE JE JE Y Y Y YE GE YE YE YE YE Y JE 3E YE JEJE YE YE 1E 1E YE Address type L Home _ Business other SweetAddress J J D JE JE Y JL YE 4E Y JE Y 3E 3E Y
55. ime of arrival to Emergency Department hh mm 24hr Clock enter 99 99 if not applicable Onset of stroke date Onset of stroke time hh mm 24hr clock Date of admission to hospital Time of admission to hospital hh mm 24hr clock Was the patient transferred from another hospital Did this stroke occur while the patient was in hospital Was the patient able to walk independently on admission i e may include walking aid but without assistance of another person AuSCR Queensland Hospital User Version 2 0 24 07 2013 21 Clinical Information questions and variables Figure 10 2 Figure 10 2 Clinical Information Section Clinical Information Was the patient treated in a Stroke Unit at any time during Unknown Y their stay Please Select v Type of stroke Please Select v Cause of stroke amp ICD10 Principal Diagnosis z Please type in a new code if it does not appear in the list ICD10 code Medical Condition Please select or add codes for this episode ICD10 code Medical Complication Please select or add codes for this episode ICD10 code Medical Procedure Please select or add codes for this episode required Was the patient treated in a Stroke Unit at any time during their stay Please select from the drop down box Yes No or Unknown Type of Stroke Please select from the drop down box Ischaemic Haemorrhagic TIA or Undetermined Important note
56. mation lv Patient deceased mm Date of death C Accurate Estimate required AuSCR Queensland Hospital User Version 2 0 24 07 2013 29 11 Searching for a Patient or to Edit Patient Data To search for a patient 1 Click the Search Patient button on the navigation menu and the Patient Search page will be displayed Figure 11 1 This page displays the list of existing patients and their corresponding episode s sorted by the date when the patient record was last updated the most recently updated record is listed first 2 Search for patients by entering the First Name Last Name or MRN or a combination of these into the search text boxes at the top of the screen and clicking the Search button 3 Click the page numbers or arrows at the top of the Patient List to scroll between the pages of patients as follows lt lt lt lt to move to the first page lt lt to move to the previous page gt gt to move to the next page gt gt gt gt to move to the last page 4 Click on the hyperlinked Patient Name to view the patient details To edit the patient details click the Edit button at the bottom of the page 5 Click on the hyperlinked Episode Id Number to view the details of a specific episode To edit an episode click the Edit button at the bottom of the page Important notes e You will only be able to search for and see patients from your hospital e Episode numbers are sequential by the date that
57. mation Sheet AUSCER mtn Stia Cited Begkny Information for patients and relatives What is the Australian Stroke Clinical Registry AuSCR The Australian Stroke Clinical Registry is an electronic data management system that collects information about what happens to people who have had a stroke or a mini stroke called a transient ischaemic attack TIA The Stroke Registry collects information from hospital information systems to tell us how well you have recovered after your stroke In order for the Stroke Registry to be successful we hope as many people as possible participate Why do we collect information for the Australian Stroke Clinical Registry Stroke affects more than 50 000 people in Australia every year and by collecting information about your hospital stay the Stroke Registry aims to ensure that patients and their families affected by stroke receive the best possible care improve stroke care and rehabilitation across Australia improve stroke treatment in hospitals prevent stroke from occurring and improve chances of recovery after stroke Who manages the Stroke Registry The Stroke Registry is co coordinated by Stroke Division of the Florey Institute of Neuroscience and Mental Health In your area the Stroke Registry is managed at name of hospital name of local investigator What information is collected when and by whom In hospital After you have agreed to participate your treating sp
58. ment following completion of coding e Proceed to complete all other data e AuSCR office will prompt you for the data throughout the year when they are missing What do do if there are no contact details e Leave fields blank Refer to the Data Dictionary What do do if the patient is from overseas e All cases are to be included unless the patient chooses to opt out e All data can be entered as usual e Record their temporary Australian contact details as other address type e Record their usual home overseas as home address type e Select Overseas as the State Territory An overseas postcode can be entered if Overseas has been selected What do do if get an error message e Press Alt Print screen simultaneously on your keyboard to capture the active screen only containing the error message e Open a word document and paste it in Write below it what happened prior to you getting the error message Save it as an error message hospital name e Email the document as an attachment to admin auscr com au How do l obtain a password e Each hospital will have a Hospital Administrator created by the AUSCR office Your Hospital Administrator can issue you with a username and password Once created your username and password will be emailed to you e f your Hospital Administrator is unavailable then contact AUSCR office to generate one for you How do edit information in the AuSCR Database
59. ms are to be stored in a secure and confidential manner in accordance with hospital policies AuSCR Queensland Hospital User Version 2 0 24 07 2013 38 17 Downloadable Reports of summary data Individual pre specified hospital reports are available to all hospital users via the AUSCR database The reports may be generated at any time and use the current data available in the AuSCR Database Therefore data in these reports have not been verified by the AuSCR office and are for internal use only Table 17 1 The downloadable reports will provide summary data for the date range selected and are provided in tables and graphs for your convenience These tables and graphs will include results from your hospital as well as a summary estimate from all the cases entered from all participating sites The Hospital Administrator also has the ability to export your hospital data into an Excel spreadsheet so you can run your own data analyses These data will also include any unlocked cases Annual reports of verified data including follow up data that have been adjusted for differences in patient case mix will be provided on the AUSCR website Your hospital will be notified when an annual report is available to download To access hospital reports 1 Click the Report button on the navigation menu 2 Click the Reports button on the navigation menu and the Select Report page will be displayed Figure 17 1 Select the Report Type from th
60. n on the navigation menu Scroll down to New User button at bottom of the User List Click on New User button Figure 5 1 Complete new user details on User page Figure 5 2 D Ot o p P Create a generic password The password must be longer than 4 and shorter than 9 characters and contain both letters amp numbers Important note Passwords are case sensitive 7 Click the Receive Email tick box 8 Select Hospital User in the Role text box 9 Select your Hospital from the drop down list 10 Click the Save button 11 An email will be automatically generated and sent to the email address you have entered Figure 5 3 Figure 5 1 Creating New User Page User Username First Name Last Name Password Confirm Password Email lv Receive Email Superuser Role required AuSCR Queensland Hospital User Version 2 0 24 07 2013 8 Figure 5 2 User Details Page AUSCE Australian Stroke Clinical Registry DET JZ User agathaf Username Agatha First Name Foilan Last Name LIII Password I Confirm Password afoilan george org au Email iv Receive Email HospitalUser M Role Royal North Shore v Hospital Q value is required required Figure 5 3 Registration Alert Emails 6 From Australian Stroke Registry admin amp auscr com au To AuSCR Admin Cc Subject Registration Alert AUSCHR Australian Stroke Clinical Registry Thank you for registering with AuSCR You have
61. nd Hospital User Version 2 0 24 07 2013 45 be provided again to each patient to explain their right to opt out any or all information in the registry and or their option to refuse to participate in the follow up survey It is essential for timely follow up of patients that their hospital data are completed within three months of their stroke or they may not be eligible for follow up 22 Error Screens Occasionally the system may encounter an error that it cannot handle In these situations please contact admin auscr com au There are several errors that will not normally need intervention from the AUSCR admin These are e Optimistic Lock Exception Figure 22 1 this occurs when more than one user tries to update the same record at the same time The system prevents this occurring because data may be lost if simultaneous updates occur If you encounter this error you will have to navigate through the right menu and reapply your updates again e Access Denied this occurs when the user tries to access a page that they do not have authority to access Figure 22 2 If you encounter this error you will have to use the menu located on the right of the screen to navigate back to an area that you do have access to Contact AUSCR office if you need to revise your user access Figure 22 1 Optimistic Lock Exceptions AUSCE Australian Stroke Clinical Registry Home Error Another user changed the same data please try again org jb
62. nd password via an email you will be able to log into the AuSCR Database Important note You must only ever access the AuSCR Database using your own username and password To login to the AuSCR Database 1 Open a web browser and navigate to http www auscr com au The AuSCR Home page will be displayed Figure 7 1 2 Click Registry Login towards the bottom of the right hand side of the page and the Login page will be displayed Figure 7 2 3 Type your username in the Username text box 4 Type your password in the Password text box 5 Click the Remember me tick box if you want the computer to automatically show your username the next time you login to the AuSCR Database 6 Click the Login button Important note you will still need to enter your password each time you login Only use Remember me function if you are the only person who will be entering data on the computer you are using AuSCR Queensland Hospital User Version 2 0 24 07 2013 10 Important note The system will timeout after 15 minutes of inactivity and you will be required to login again Figure 7 1 AuSCR Home Page AUSCE Australian Stroke Clinical Registry Home Patients and Family Members Health Professionals Research AuSCR Contact Us PATIENTS amp FAMILY MEMBERS Learn about how you can support the Australian Stroke Clinical Registry and how we protect your personal information read more Latest News HEALTH PROFE
63. ndication of potential dysphagia and or aspiration risk A swallow screen can be used to identify patients who require further assessment by a Speech Pathologist For further information please refer to the AuSCR Queensland Data Dictionary Examples of formal swallow assessment tools may include but are not limited to the ASSIST Toronto Bedside Swallowing Screening Test TOR BSST or 1 2 1 screening tool Queensland Health Dysphagia Screening Assessment 2006 Speech Pathology Department RBWH AuSCR Queensland Hospital User Version 2 0 24 07 2013 24 Please select from the drop down box Yes No or Unknown Note There are no additional data entry fields for this question Figure 10 4 Dysphagia screening tool information Please Select v Dysphagia screen tool used Please Select Yes No Unknown Was screening or assessment of swallow conducted prior to any giving oral intake medication food fluids Figure 10 5 Is there evidence in the medical records that the patient has received a formal swallow assessment or a swallow screen by a trained staff member prior to receiving any form of oral intake For further information please refer to the AUSCR Queensland Data Dictionary Please select from the drop down box Yes No or Unknown If the answer is Yes this will expand the section to display additional data entry fields Screen result Normal or Abnormal Date of screening Select a date using DD MM YY
64. ng women condition of increased mast cells inadequate vitamin K anemia from pyruvate kinase and G6PD deficiencies gout anemia decrease in the blood clotting protein prothrombin Von Willebrand s disease Date of screening Select a date using DD MM YYYY format or use the embedded calendar next to the date box to permit auto completion of dates AuSCR Queensland Hospital User Version 2 0 24 07 2013 26 Please indicate whether this date is accurate or an estimate by clicking on the appropriate radio button Time of screening Select the time using the 24 hour clock format hh mm Please indicate whether this time is accurate or an estimate by clicking on the appropriate radio button Figure 10 7 Aspirin administration information Aspirin given within 48 hours 24 10 2012 Date of commencement Accurate Estimate 08 00 Time of commencement hh mm 24hr clock Accurate Estimate required Important note Once all of the clinical information has been entered click the Save button at the bottom of the page before entering the discharge information Discharge Information 1 Click the Date of discharge known tick box if applicable This will expand the Discharge Information section to display additional data entry fields 2 Type or use the embedded calendar to select the Date of discharge Indicate whether the date is Accurate or an Estimate by clicking one of the corresponding radio buttons
65. nsland Hospital User Version 2 0 24 07 2013 43 Table 18 1 Summary of the worksheets Worksheet Linked Worksheet Link Hospital Patient Record Hospital Id Hospital Follow Up Patient Hospital Id Person Patient Record Person Id Person Follow Up Patient Person Id Patient Record Patient Record Follow Up Patient Follow Up Patient Patient Address Patient Contact Follow Up Patient Address Follow Up Patient Contact Patient Record Id Emergency Contact Id Alternate Contact Id GP Contact Id Follow Up Patient Id Emergency Contact Id Alternate Contact Id GP Contact Id Follow Up Id Follow Up Patient Follow Up Questionnaire 19 Importing Data The AuSCR database has an option available for hospitals that would like to have their data imported into the webtool to reduce data entry Please contact the Data Manager at AuSCR office for this option 20 Encryption of Excel Workbooks Encrypting Excel workbooks for transmitting stroke data to AuSCR 1 Open the saved Excel file you wish to password protect then click Tools Options 2 This will open the Options screen Click the Security tab Fig 20 1 3 Click the Advanced button to the right of the Password to open field Figure 20 1 Security tab View Calculation Edit ie Transition Custom Lists chat Color International Save Error Checking Spelling File encryption settings For this workbook Password to open e Advanced File sh
66. office following a pre arranged site visit may also be undertaken to assess the accuracy of data The registry data collection processes and conformity with variable definitions will also be assessed during this site visit This process usually occurs after the first 50 cases have been entered followed bi annually unless concerns about data quality have been identified 24 Feedback Your feedback is valuable to assist us with further improvements to the database and registry processes and procedures AuSCR will generally schedule feedback one week following initial training and one month following commencement of data collection As required please email any other feedback to admin auscr com au 25 Frequently Asked Questions What do I do if the same person is entered twice e f you enter a new patient with the same First Name Last Name Date of Birth and Medicare Number as an existing patient the system will automatically find the existing patient record and display their details for editing rather than creating a duplicate record for the same person AuSCR Queensland Hospital User Version 2 0 24 07 2013 47 e Ifthe same person is entered twice because incorrect data has been entered in one of the records you can request that the incorrect record be deleted following the steps outlined in Section 14 of this manual What do do if don t know the ICD10 code e The ICD10 codes must be obtained from the Medical Records Depart
67. ore the record is actually deleted To request the deletion of a patient episode 1 Search for the patient to be deleted View the patient to be deleted by clicking on the hyperlinked Name Click the Delete button a warning panel will appear Figure 14 1 Click the Yes button to confirm the deletion or the No button to cancel the deletion If the Yes button is selected the Status of the patient will now appear as Inactive Oy S a es I The patient record requested for deletion will automatically be added to the Delete Episode List This list is only accessible to Superusers and the Data Manager from AuSCR office 7 The Superuser or the Data Manager from AuSCR office will perform the actual deletion using the Delete Deletion List during scheduled data management processes AuSCR Queensland Hospital User Version 2 0 24 07 2013 32 Important note Actual deletion can only be performed by a Superuser or the Data Manager Deleting a patient will delete all associated episodes linked to the patient Once deleted it cannot be reversed Figure 14 1 Delete Patient Warning Warning Are you sure you want to mark the patient record for deletion icida ixl 15 Request to Opt out Data from AuSCR A patient who has been added to the AuSCR Database may request to opt out or have certain data elements removed e g their contact information AuSCR Hospital Users need to request to have these data removed by the
68. oss seam exception class org jboss seam handledException class class javax persistence OptimisticLockException org jboss seam exception message org jboss seam handledException javax persistence OptimisticL ockException org jboss seam exception rootCause Please contact admin auscr com au AuSCR Queensland Hospital User Version 2 0 24 07 2013 46 Figure 22 2 Access Denied AUSCE Australian Stroke Clinical Registry LEY Home Access Denied You don t have sufficient permission to perform this operation To gain access please contact admin auscr com au with your username and details of the task you are trying to perform 23 Quality Assurance Data Management Processes The AuSCR Database has many in built logic checks in place to prevent inaccurate information being entered However additional data checking processes are required by the AuSCR office at routine intervals This will include e The AuSCR office running routine data queries which will identify missing data and data discrepancies These reports will be sent to the hospital administrator hospital user for verification prior to locking the patient episodes e Cross referencing of ICD10 discharge codes from the hospital patient administration system database with cases entered in the AuSCR database to ensure all eligible admission have been captured may be requested up to twice a year e Random medical record auditing by the AuSCR
69. perform a calculation or express a time as Accurate If a time cannot be clearly determined use the following guidelines see Table 10 2 for estimating times in conjunction with other times that are recorded E g the time of arrival to the Emergency Department e As the last resort if a time is unknown enter 99 99 AuSCR Queensland Hospital User Version 2 0 24 07 2013 20 Table 10 1 Hints for Recording Time Time Record Time as Midnight 12 00 am 23 59 Noon 12 00 pm 12 00 12 15 am 00 15 6 00 am 06 00 4 00 pm 16 00 Table 10 2 Guidelines for Estimating Times Description of Time Record Time as The middle of the night 03 00 Breakfast 08 00 Early morning 08 00 Morning 09 00 Late morning 10 00 Lunch 12 00 Midday or 12 Noon 12 00 Early afternoon 14 00 Afternoon or mid afternoon 15 00 Late afternoon 16 00 Dinner Supper 18 00 Early evening 19 00 Evening 21 00 Late evening 22 00 Figure 10 1 Admission Information Section Admission Information C Accurate Estimate accurate Estimate accurate Estimate C Accurate Estimate c Unknown v Unknown v Unknown v Accurate Estimate Accurate Estimate Date of arrival to Emergency Department enter 01 01 1900 if not applicable T
70. r farnily if patient has severe aphasia or cognitive impaiments C Not applicable Unknown Place in appropriate boxes C Medical information J Personal information J Do not wish to be contacted for follow up Form completed by MIVIRISIZ Jes emz r2 JC Y X JC JE LC JOLIE ICI Date ZBL 2 e 12 Contact Number cJ 2 eXeletela AuSCR Queensland Hospital User Version 2 0 24 07 2013 Patient Name Betty Bobble DOB Ol 04 Id 7 Hospital Royo Tanecus C Attachment 3b Example of Poorly Completed Acute Data Collection Form DATA COLLECTION FORM i7 EN D ea oe x E QUEENSLAND Australian Stroke Clinical Registry Pigaso complete the form Return form to AuSCR Office via Neatly and legibly Fax 02 8507 2531 M Write in black ink and press firmly Or Each question must be completed Post AuSCR Office c o TGI PO Box M201 Place v in appropriate boxes Missenden Road Camperdown NSW 2050 Ee completed Hospit l Name AFFIX PATIENT STICKER HERE Patient Informa TE Title C MIRAH ra UP BE EHE 2 grege yr Tre Je re LG E JC JC JC 3C JC JC JC JC JC JE JC JC JL JE Biel rir MOOOooooonooooooooooooooo Address type Home L Business J Other SweetAddress Jf D JL JL YT JE JC JL JEJE YE JC C JC JC JE JC JC JE JC JC JE JC JC JE JC JC Suburb LJE JE JE JE E CE JE JCYEJEJCOE TEE JC ECC JC 30 3C C JEJE JC EC C
71. rocedure ICD10 code Clicking the Add button will append the code to the list box under the Add button Important note To remove a code from the list box select the code in the list box then click the Delete button Was the patient mobilised this admission Figure 10 3 For further information please refer to the AuSCR Queensland Data Dictionary Please select from the drop down box Yes No or Unknown If the answer is Yes this will expand the section to display additional data entry fields Date of first documented mobilisation Select a date using DD MM YY YY format or use the embedded calendar next to the date box to permit auto completion of dates Please indicate whether this date is accurate or an estimate by clicking on the appropriate radio button Select method of first mobilisation from next drop down box This includes sitting over the edge of the bed or in a chair standing and walking This method should be documented in the medical records Figure 10 3 Mobilisation Information Yes Was the patient mobilised in this admission 24 10 2012 Date of first documented mobilisation Q Accurate C Estimate Sitting v Method of first mobilisation Please selectthe one method Assisting the patient upright and out of bed this includes documented within the medical record Sitting over the edge of the bed Dysphagia screening tool used Figure 10 4 Swallow screening provides an i
72. roke Clinical Registry AuSCR is collaborative national effort to monitor promote and improve the quality of acute stroke care We believe that by working together patients families clinicians and researchers can make a difference in the lives of Report x people affected by stroke Table 8 1 Features of the Navigation Menu Navigation Features Provided Access Menu Logout This button allows you to securely log Hospital User out of the AuSCR Database User Account Reset Password Enables you to change your password Hospital User Patient New Patient Allows you to add a new patient Hospital User including personal information addresses contacts and episode data Search Patient Allows you to search for an existing Hospital User patient by first name last name or medical record number Report Reports Allows you to download pre specified Hospital User hospital reports Please note that the data in these reports have not been verified by the AuSCR office and are for internal review purposes only Data Export Excel Allows for export of fraw data from Hospital your hospital input into an Excel Administrator spreadsheet Import Excel Allows for XML import from hospital AuSCR Office database to AUSCR AuSCR Queensland Hospital User Version 2 0 24 07 2013 12 9 Adding a New Patient Important note Fields with a are mandatory To add a new patient 1 Click the New
73. rt Form The order of the columns is mandatory The first row is assumed to be a header row All data must be saved as text including dates and numbers All dates must be formatted as DD MM YYYY Each column attribute has specific data type text or has a set of predefined values compatible with METeOR standards Data Entry Constraints The system requires as a minimum the following data 1 It is recommended no more than 500 rows be in one import per spreadsheet If there are more than 500 records break up the records into several imports First Name given or Christian name Last Name or Surname MRN local primary key identifier of the Patient in the Hospital HIS Date of Birth patient s date of birth DD MM YYYY Date of Admission date that the patient was actually admitted to acute care or inpatient unit of the hospital This is not the date of arrival to ED 7 The First Name Last Name Date of Birth Medicare number Hospital Identifier and Admission date will create a new record for the patient If a duplicate is detected during import processing the data will be updated to the database for that patient record o 0 R wD 8 Refer to the Data Dictionary for specific definitions of data values 9 Refer to the ImportSpecification xls for data specifications AuSCR Queensland Hospital User Version 2 0 24 07 2013 50 Data Mapping Refer to the spread sheet ImportSpecification xls for specific inst
74. rth and Language Spoken from the drop down lists The 10 most common countries languages appear at the top of the lists with all others listed below in alphabetical order Typing in the first letter will move you to the next country language in the list starting with that letter Each time a new letter is typed you will be moved to the next country language starting with that letter 7 If required click the nterpreter Needed box to mark it with a tick This box cannot be marked if English is selected as the Language Spoken AuSCR Queensland Hospital User Version 2 0 24 07 2013 14 Figure 9 2 Patient Record Page Personal Information Patient Record Personal Information Jane Doe Name Please Select Title Hospital Medical Record Number Gender Phone Number Mobile Number Is the patient of Aboriginal Torres Strait Islander Neither Aboriginal nor Torres Strait Islander origin origin Please Select v Country of Birth Please Select v Language Spoken E Interpreter Needed required To add addresses 1 Click the Mailing Address tick box if the address being entered is to be used as the mailing address At least one address has to be ticked as a mailing address 2 Select the Address Type from the drop down list 3 Type in the Street Address in the Street Address text box 4 Type Suburb into the Suburb text box 5 Select the State from the drop down list or Overseas if applicable 6 Typ
75. ructions for each column attribute This document specifies the meta data characteristics for each of the imported data values The following specifications are covered 1 Optionality amp Notes whether the attribute is mandatory or optional and any clarification notes Representation Class broad information category text identifier code etc Data Type is always String Format where applicable a representation of how the data needs to be formatted Max character length the maximum length of the valid string for a variable 9r DV de o Y Scope of Values amp Notes where applicable lists the scope of all possible values and notes on usage for correct data mapping Uploading Committing Data It is possible for users to upload data directly to AuSCR through the web interface The AuSCR system will return a message if successful If a problem occurs with the data the AuSCR system will return a row number and error message to identify the problem The system will not allow data to commit until all errors have been resolved Initially users will send their data as an encrypted attachment to the AuSCR office where the data are analysed and uploaded to the AuSCR system Feedback will be provided to the hospital user and or local IT support to improve the quality of the imported data and facilitate data entry AuSCR Queensland Hospital User Version 2 0 24 07 2013 51 Attachment 1 Example of Patient Infor
76. sed box if applicable This will expand the Death Information section to display additional data entry fields 2 Type in or use the calendar to select the date of death and indicate whether the date is Accurate or an Estimate by clicking one of the corresponding radio buttons Important notes e lfa patient is discharged from hospital but dies before data entry is complete or if a patient is known to have died within 3 months of admission please enter death data so that the AUSCR office staff do not contact family members to complete a 3 month follow up questionnaire The AuSCR Database includes logic to minimise data entry errors e g Date of death cannot occur before Date of birth If you do not complete all of the mandatory fields in the admission screen an error message will alert you when you click save However should you attempt to ignore the message and exit the screen none of the information will be saved Once all of the data have been entered click the Save button at the bottom of the page to save the Episode information An Admission Information page will be displayed showing all information entered for the episode Important notes When Completion Status shows Incomplete it means you can return to the episode at a later stage and make changes to complete the data collection You should not Complete the episode until all known episode details have been entered Figure 10 9 Death Information Death Infor
77. sked if you would like to be contacted in the future to receive more information about stroke or participate in future research studies that might be appropriate for you A decision on whether or not you wish to be contacted about future research projects does not affect your registration in the Registry If you agree the Registry staff will be responsible for contacting you You are under no obligation to participate and can change your mind at any time If you have any questions about the Stroke Registry would like further information or have any other Registry related issues please contact the AuSCR Project Coordinator on telephone 1800 673 053 or email admin auscr com au Any person with concerns or complaints about the Stroke Registry can contact the Executive Officer of the insert name of Research Ethics Committee on Insert phone number or email insert email The Stroke Registry project has beenapproved _ _____ ________ ____ ___ _ ___ __ _ by the name of relevant research ethics committee OPT OUT FORM Please tick the box next to the information you do not want recorded in the Registry Database do not wish to have the following information included in the Australian Stroke Clinical Registry AuSCR O Medical information information about your stroke O Personal information information such as your date of birth address and GP contact details I do not wish to be O contacted after discharge and asked about how am m
78. ssions The AuSCR office requires that a form is completed for each opt out received The original signed copy of the opt out form should be kept in the medical record and a copy faxed to the AuSCR office secure fax number on 03 8888 4990 Please note If a patient is discharged before being given an AuSCR Information Sheet they must be sent this information sheet along with the Patient Contact Post Discharge letter prior to their three month follow up Attachment 6 General Information about the AuSCR Database The following information should be understood by all AuSCR Database users The term click is used throughout this manual to refer to a left mouse click Mandatory fields are denoted by a red asterisk If you fail to enter data for a mandatory field an error message will flash onto the screen when you try and save data on that particular page of the AuSCR Database Blue labelled buttons are used throughout the AuSCR Database and require a left mouse click to activate Data are entered into the AuSCR database using 1 Text boxes a blank white box into which you type data Example Textbox Name Before typing data you must ensure the cursor indicated by a flashing black bar is in the correct field text box To move the cursor to a text box click in it The Tab button on your keyboard can be used to move to the next field text box AuSCR Queensland Hospital User Version 2 0 24 07 2013 5 2
79. stimate by clicking on the appropriate radio button Time of screening Select the time using the 24 hour clock format hh mm Please indicate whether this time is accurate or an estimate by clicking on the appropriate radio button Figure 10 6 Speech Pathologist swallow assessment Yes v Formal speech Pathologist swallow assessment 24 10 2012 Date of assessment Accurate Estimate 14 00 Time of assessment hh mm 24hr clock Accurate 9 Estimate Aspirin given within 48 hours For ischaemic stroke or TIA Figure 10 7 For further information please refer to the AUSCR Queensland Data Dictionary Please select from the drop down box Yes No or Not Applicable Has the patient has received Aspirin within 48 hours of onset of stroke symptoms If the answer is Yes the section will be expanded to display additional data entry fields Note Not Applicable would only be entered in the following cases e The patient has experienced a haemorrhagic stroke where the administration of Aspirin would be highly contraindicated e The patient has been administered another anti platelet or anti thrombotic e Aspirin is contraindicated due to an allergy to salicylate a pre existing or existing medical conditions such as but not limited to active gastric ulcers asthma haemophilia Reye s Syndrome thrombotic thrombocytopenic purpura acute liver dysfunction acute kidney disease pregnancy lactating breast feedi
80. t details entered If you have noted an error such as an incorrectly spelt name you may request that AUSCR office fix these minor corrections Please prepare a list of all the changes and email them to the Data Manager admin auscr com au If you enter a new patient with the same First Name Last Name Date of Birth and Medicare Number as an existing patient the system will automatically find the existing patient record and display their details for editing To create a new episode of care for an existing patient refer to Section 10 Adding a New Episode page 19 The Patient Record page is used to add further patient information under the headings Personal Information Address and Contacts Figure 9 2 To add personal information 1 Select the patient s Title from the drop down list Once title is selected the gender will appear automatically 2 Type in the Hospital Medical Record Number Important note This is a mandatory field 3 Select Gender if the title selected is Dr or if the title is unknown For all other titles the gender cannot be altered 4 Type in the Phone Number including area code and Mobile Number In the case of international landline phone numbers there is only space for 10 numbers therefore only the phone number can be entered exclude the international and the area codes c1 Select the Aboriginal Torres Strait Islander origin from the drop down list 6 Select the Country of Bi
81. t OOOOOOOE ee awae cesas Time of stroke onset LILILILI 24 hourciock L Accurate Estimate Date of admission LLL ILL IL IL IL ess Oasa O estimate Time of admission LILILILI 24 hour clock D Accurate 7 Estimate Was the patient transferred from another hospital O Yes O No CO Unknown Did this stroke occur while the patient was in hospital O ves O No C Unknown Able to walk independently on admission e may include walking asd but without assistance fron ves O No C unknown Is there documented evidence of a previous stroke O Yes C No Clun e focal neurological signs persisting for more than 24 hours Was the patient treated in a Stroke Unit at any time during their stay O ves O No O Unknown Type of stroke OTa O ischaemic C Haemorrhagic C Undetermined If an ischaemic stroke did the patient receive intravenous thrombolysis tPA 1 Yes C No O Unknown Cause of stroke L Known C Unknown Diagnosis O00 Medica condition JI 1L 1E 1 OO00 OO00 ICD10 codes Complication E JL 1L O000 0000 Procedures O O000 0000 0000 0000 Was the patient mobilised in this admission O Yes O No Unknown Date of first documented mobilisation LILWMEILVEIE TII adimm yyyy LlAccurae Estmate Method of first mobilisation itti CStanding Walking ssisung Ne pave u ne one thod documented within the sitt over the edge of the bed Dysphagia Screen Tool used O Yes O No Was screening or assessment of swallow conducted prior oy O No to an
82. t Warning Are you sure you want to opt out this person Fig t out information saved ure 15 3 O AU NH Welcome Superuser Logout Australian Stroke Clinical Registry _ Administration mm cmm Hospitals Welcome to the Australian Stroke Clinical Registry Merge Records Opt Out The Australian Stroke Clinical Registry AuSCR is collaborative national effort to monitor promote and improve the quality of acute Opt Out Report stroke care We believe that by working together patients families clinicians and researchers can make a difference in the lives of people affected by stroke View Incomplete Episodes Delete Patient List The data collected in AUSCR will be used to guide quality improvement interventions in hospitals to ensure best practice stroke care Delete Episode List The data can be used to reduce variations in care delivery and ultimately provide evidence of reduced deaths disability and recurrent strokes from improvements in stroke care UserAccount AuSCR is a free service that offers hospitals a secure online interface which Patient New Patient e stores patient data Search Patient e provides clinicians with downloadable reports summarising patient data e allows hospitals to export their data to Microsoft Excel for local analyses and FolowUp v e provides annual performance reviews newsletters and publications Repot v Please contact admin pauscr com au to enq
83. ta by admission date or leave as blank to export all accessible episode related records Queensland Test Hospital Hospital 01 05 2012 Ti From admission date 02 07 2012 w To admission date Important note The data will be exported to an Excel workbook containing a series of worksheets showing some of the variables from the Database i e hospital users only have the acute hospital data available for export These worksheets include several unique numeric identifiers that can be linked to a patient Unfortunately the unique identifiers for a patient person ID and patient record ID are not always reported on each worksheet so care is needed if wanting to link data between one worksheet and another The system was designed this way since patients may have multiple admissions to the same hospital for different stroke events which are then eligible to be recorded as a different episode of care Patients may also go to different hospitals To enable an individual patient to be tracked in the AuSCR Database each individual is assigned a unique Person ID For a particular hospital they will have a Patient ID created and each episode of care will also generate a unique Episode ID In addition for each contact list for a patient a Contact ID will be created e g Emergency Alternate and General Practitioner The relationships between the worksheets and the IDs available in each worksheet are summarised in Table 18 1 AuSCR Quee
84. th Stroke Division Melbourne Brain Centre 245 Burgundy Street Heidelberg VIC 3084 To speak with your treating doctor about the importance of the Stroke Registry please contact HOSPITAL CONTACT NAME on HOSPITAL TELEPHONE NUMBER Yours faithfully U Lata SIGNATURE Name of Patients Primary Treating Physician Assoc Prof Dominique Cadilhac Title AuSCR Principal Investigator Name of Hospital Enc Patient Information sheet amp Opt out form Qld AuSCR Qid PatientContactLetterPost Discharge VersionS 1 280ctober2013 Clean doc AuSCR Queensland Hospital User Version 2 0 24 07 2013 69
85. the Database from the New Patient screen To download a copy of the AuSCR Queensland Acute Data Collection form Log in to the Database Click the New Patient button on the navigation menu and the New Patient page will be displayed Click on the hyperlinked Download paper based Qld hospital data form Figure 16 1 The Acute Data Collection form will be displayed which can then be printed Figure 16 1 Download Queensland Acute Data Collection Form Click here 4 a ope a EBP Welcome Steven Australian Stroke Clinical Registry Administration New Patient User Account Patient New Patient Dow e D o pi d Download paper based LD hospital data forr Search Patient Follow Up Report Date of Birth Import Excel Medicare Number ieensland Test Hospital se Hospital Using the Queensland Acute Data Collection Form The form can be filled out on the ward during the hospital stay The form should be checked at patient discharge and any missing data entered The person responsible should sign and date the completed form Once the form has been completed the data can be entered into the AuSCR Database Good Clinical Practice guidelines must be used in completing the forms NHMRC National Statement with TGA annotation ICHGCP CPMP 135 95E6 Examples of correctly completed and poorly completed forms are attached Attachment 3a and 3b AuSCR Queensland Hospital User Version 2 0 24 07 2
86. the Principal Diagnosis is not stroke or the stroke codes provided do not match the Medical Record Principal Diagnosis then enter this code directly into the Principal Diagnosis box This text box will only permit valid ICD10 codes to be entered according to the following format ANN N N refer to the Data Dictionary for details 2 ICD10 code Medical Condition Enter an ICD10 code for the Medical Condition s available from the Medical Record into the drop down list The system will attempt to auto complete the code After entering each code click the Add button before entering the next Medical Condition ICD10 code Clicking the Add button will append the code to the list box under the Add button 3 ICD10 code Medical Complication Enter an ICD10 code for the Medical Complication s available from the Medical Record into the drop down list The system will attempt to auto complete the code After entering each code click the Add button before entering the next Medical Complication ICD10 code Clicking the Add button will append the code to the list box under the Add button AuSCR Queensland Hospital User Version 2 0 24 07 2013 23 4 ICD10 code Medical Procedure Enter an ICD10 code for the Medical Procedure s that is are available from the Medical Record or hospital records into the drop down list The system will attempt to auto complete the code After entering each code click the Add button before entering the next Medical P
87. uire about participating in AuSCR Daa v To log into the AUSCR database please use the LOG INTO AUSCR button provided at the top right hand side of this screen The data entry screens throughout AuSCR have brief explanations and tips that may assist you during data entry are experiencing any difficulties or would like to have AuSCR help notes sentto you by email please contact admin m 16 AuSCR Queensland Acute Data Collection Form The AuSCR Queensland Acute Data Collection Form is a hard copy version of the variables to be recorded in the AuSCR Database Since Queensland has additional variables which are not used in other states please ensure that you use the correct Acute Data Collection Form The Acute Data Collection Form Attachment 3 is available for e Hospitals that are not entering data directly from the medical record into the AuSCR Database e Hospitals experiencing technical difficulties using the AuSCR Database e Hospitals that do not have the capacity to enter data into the AuSCR Database AuSCR Queensland Hospital User Version 2 0 24 07 2013 36 Obtaining Acute Queensland Data Collection Forms The AuSCR office can send the Acute Queensland Data Collection forms to you via email as a PDF document mail when contacting the office provide a name and mailing address where the forms can be sent along with the number of forms required or alternatively Download directly from
88. ument properties cma Important notes A strong password has the following properties e Minimum of 10 characters e Complexity of characters use both alpha numeric and mixed case characters AuSCR Office will negotiate with user and send via email to the user Send your password protected file as an email attachment and clearly state your site ID and period that the data cover to admin auscr com au Ensure that you have saved a copy of each file in a local hospital computer directory for AuSCR data Each file should be given a unique name which will ensure each new set of extracted files are not duplicated or misplaced For example the date range should be listed as part of the file name To Import Data use the AuSCR Import Excel Data Screen Currently data is uploaded by AuSCR office staff Once a reliable version of the import file can be independently produced at the local hospital a hospital user can import their file directly into AuSCR 21 Follow up Approximately three months but up to six months after admission to hospital patients will be followed up by AuSCR staff via a postal and or telephone survey They will be asked to complete questions about their current living circumstances and health status including questions about their quality of life To assess quality of life the EuroQol or EQ 5D is used for adults and the PedsQL is for those aged less than 18 years At this time information will AuSCR Queensla
89. w gov au content index phtml itemld 181 162 Where a METeOR definition does not exist we have used the definitions from reputable international stroke organisations the National Stroke Foundation and the Queensland Statewide Stroke Clinical Network 5 How to Obtain a Password Each hospital will have a Hospital Administrator created by the AuSCR office The Hospital Administrator is then able to create all Hospital users To request a user name and password to access the AuSCR Database the Hospital Administrator must 1 Complete a User Request form Attachment 5 and email or fax it to the AuSCR office Contact the AuSCR Office to obtain a form either by email or fax 2 A Registration Alert email will be generated with your username and password and sent to you 3 You must change the generic password given to you when you first login to the AuSCR database To become a Hospital User 1 Complete a User Request form Attachment 5 and email or fax to the AuSCR Hospital Administrator for your hospital AuSCR Queensland Hospital User Version 2 0 24 07 2013 7 2 A Registration Alert email will be generated with your username and password and sent to you 3 You must change the generic password given to you after you login to the AuSCR database for the first time How to create a Hospital User if you are a Hospital Administrator 1 Click the Administration button on the navigation menu Click the Users butto
90. y 2000 gt gt gt x Sun Mon Tue Wed Thu Fri Sat h w A on m co ab 12 13 14 15 16 17 18 19 20 21 22 231 24 25 26 27 28 29 ne ww N e e b b cm e Ww _ Today AuSCR Queensland Hospital User Version 2 0 24 07 2013 6 e To use the calendar click the calendar icon to the right of the text box and click the date required e Click the Today button at the bottom of the calendar to enter today s date e Click the arrows at the top of the calendar to navigate as follows lt lt to move back by one year to move back by one month gt to move forward by one month gt gt to move forward by one year x to close the calendar 6 Episode An Episode details the care provided in hospital to a patient Patients can have multiple episodes e g if they are readmitted to hospital for a recurrent stroke This section is where patient clinical data are recorded It is preferable that episodes are recorded in chronological order However if the episode IDs are not sequential it will not be a problem 7 Saving Data Clicking the Save button at the bottom of the page will save the variables that have been entered 8 Variable Definition All variables collected are defined in the AuSCR Data Dictionary Attachment 4 Variable definitions and formats where possible are consistent with the electronic National Health Data Dictionary METeOR http meteor aih
91. ylgiving oral intake medication food fluids Screen Result C Nomad sam EEEEICETTI m Time of Screening LILILIL 29 O Accurate 0 Estimate Formal Speech Pathologist Swallow Assessment Date of Assessment AuSCR AcuteData CollectionForm Queensland V4 28October2013 Clean docx 34 AuSCR Queensland Hospital User Version 2 0 24 07 2013 57 Patient Name DOB Hospital Aspirin given within 48 hours Date of Commencement Patient Deceased No O Yes date of death JL VL TL YE JL iddimmiyyyy O Accurate O Estimate Discharged Alive a Date of discharge LIJCVC JL VETE ILL 59m O Accurate O Estimate b Discharge O Transfer to other hospital C Home with support destination mode acute C Home without support SNAP still in hospital O Transitional care services C Rehabilitation inpatient Died in hospital L Low level Residential Care 0er O High level Residential Care c Discharged with antihypertensive agents O Yes O No CO Unknown a Discharged with antiplatelet antithrombotic O Yes O No C Unknown b Is there evidence that a care plan outlining post discharge care in the O ves O No community was developed with the team and the patient or family if patient has severe aphasia or cognitive impairments C Not applicable Unknown Place 7 in appropriate boxes Place 7 in appropriate box CO Opt out medical information O Does not wish to be contacted for follow up survey at 3 8 months post stroke

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