I'm looking for an audit that will show me all the content within my forms (obs terms and responses associated to obs terms). In addition, looking for a audit that will tell me what forms a specific obs term lives.
I'm not sure I understand what you're looking for. What type of forms? CCC, VFE?
The obs term value data flow is one-way. IOW, once a value is committed for an obs term in a form (or any other method), it is written to the database. Once it is written to the database, I don't think there is any tracking on where the value originated (form or other method).
As for your second request, if you're asking what obs terms are generated from particular forms, that actually could be quite useful to know. The only way I know to determine it is submit a form, then look at the flowsheet to see what obs terms were populated. Definitely not a friendly procedure.
As an example, I want to know all the forms that contain Blood Pressure.
The issue there is there are about 50 (just a guess) different obs terms for BP. You have standing, sitting, supine, left arm, left leg, right arm, right leg, etc. Each one is a different observation term.
Exactly - I'm having a team build reports and I want to provide:
1) where the documentation is coming from
2) if the obs term is being used
3) provide my report writers a list of obs terms to call out that are actually being used
In the ideal world I would also like to know the responses attached to the obs term in the cases where a multi-select and drop options are available.
There are two potential approaches that come to mind, other CHUG users will certainly have other thoughts.
1. For VFE centric practices, there is a text file generated for each form listing the observation terms used. In a Coumadin form a wrote, ACG Coumadin v1.dlg, there is an associated file ACG Coumadin v1.txt. A partial listing of the file looks like the following:
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CLINICAL KIT: F:\ACG VFE Forms\JWF\ACG Coumadin v1.ckt
FORM NAME: ACG Coumadin
This form uses the following observation terms:
Short Name HDID Type Units Description
--------------- --------------- ----- ---------- ------------------------------------
A&P#1 31410 T Assessment & Plan #1
PROTIME DX 2400001 T anticoagulation treatment, indication for
COUMSTRTDTE 20783 T Coumadin start date
INR RANGE 1600002 T international normalized ratio (INR) range
DURATION 2876 T duration
COUM OTR MD 145183 T Other Provider, Coumadin
CARE LOC 18950 T location of care
CM ASSES CO 125850 T Coumadin assesment comments
WARFMDT COM 146647 T Warfarin med/diet comments
BP SYSTOLIC 54 N mmHg blood pressure, systolic - 8480-6
BP DIASTOLIC 53 N mmHg blood pressure, diastolic - 8462-4
PULSE RATE 56 N /min pulse rate E&M - 8867-4
BLEEDNGSIGNS 35453 T signs of bleeding
INR 309 N international normalized ratio (INR)
PROTIME 109753 N Protime
COUM TAB MG 4800008 T Coumadin tab strength
MONDAY DOSE 4800031 T Coumadin dose, Monday
TUESDAY DOSE 4800044 T Coumadin dose, Tuesday
WEDS. DOSE 4800050 T Coumadin dose, Wednesday
THURS. DOSE 4800043 T Coumadin dose, Thursday
FRIDAY DOSE 4800014 T Coumadin dose, Friday
SAT. DOSE 4800038 T Coumadin dose, Saturday
SUNDAY DOSE 4800039 T Coumadin dose, Sunday
COUM TOT WK 6679 T Coumadin, total dose for week
CCNEXTVISIT 80047 T Coumadin Clinic Next Visit Date
COUMADIN CHG 134600005 T Coumadin dose changes
CM INSTR CO 125851 T Coumadin instruction comments
DOCTOR RN1 16600022 T Coumadin, physician or nurse who ordered
WARF IND COM 88724 T Indication comments for Warfarin use
This form uses the following observation terms not included in your database:
This form uses the following flowsheet views:
Enterprise\ACG\Coumadin
This form uses the following problem custom lists:
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All (!!!) you need to do, is parse each form associated .txt file. This is not impossible. The other option is cut and paste from the .txt file into spreadsheet, then sort and summarize.
2. You could also approach this from the document side. Each document is associated with an encounter. The forms for the encounter can be determined, and the obs terms for the encounter can be summarized from their associated document. This is potentially simpler, the down side being the obs terms doesn't identify the form within the encounter, and obs terms that are not used won't be listed.
Good luck, I'm interested in how you solve this problem.
When I've had to find where an obs term is being used and what options are setup up for it already, I do the following. Export the clinical kit(s), and then use a file searcher. (I use Agent Ransack.) This quickly gives me a view of what forms use the term, and what's associated with it.
It does take a bit of time to manually reconcile things, but it works for me.
Thank you everyone for your feedback. I'm in the process of downloading the Agent Ransack. Fingers crossed and happy dance when it works!