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Hospital User Manual

1. 2 Representation Class broad information category text identifier code etc 3 Data Type is always String 4 Format where applicable a representation of how the data is formatted 5 Max character length the maximum length of the valid string 6 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 there is a problem 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 is 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 Hospital User Version 9 10 11 2010 52 Attachment 1 Example of Patient Information Sheet AUSCE Information for patients and relatives Australian Stroke Clinical Registry 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
2. 2 Is there documented evidence of a previous stroke Unknown Clinical Information Was the patient treated in a Stroke Unit at any time during their stay Yes I No J Unknown Type of stroke LITIA Ischaemic Haemorrhagic Undetermined If an ischaemic stroke did the patient receive intravenous thrombolysis tPA Yes C No Unknown Cause of stroke LI Known Unknown ICD10 code Diagnosis IL Separation Discharge Information Patient Deceased No Yes date of death _ LJ Accurate Estimate Discharged Alive a Date of discharge Accurate Estimate b Discharge U Hospital U Home with support destination mode Rehabilitation Inpatient Home without support Low level Residential Care Transitional care services High level Residential Care Died in hospital Other c Discharged with antihypertensive agents L Yes No Unknown d Is there evidence that a care plan outlining post discharge care in the O Yes O No community was developed with the team and the patient and or family if patient has severe aphasia or cognitive impairments L Not applicable Unknown Opt Out Request Place in appropriate boxes C Medical information Perso
3. Neither Aboriginal nor Torres Strait Islander origin wv origin Please Select Nj Country of Birth Please Select v Language Spoken m 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 Important Note The default option is Home 3 Type in the Street Adaress 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 Type 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 fitis an overseas address select Overseas for the State and this will allow free text in the Postcode box to enter an overseas postcode 8 Select the Country from the drop down list AuSCR Hospital User Version 9 10 11 2010 15 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 10 3 Figure 10 3 Patient Address Section Address Iv Mailing Address Home Address Type 123 George St Street Address Sydney NSW 2000 Suburb State Postcode Australia mu __ Country Contacts Important Note Any existing a
4. 18 11 Adding a New Episode The AuSCR Database requires that clinical information data 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 recorded for every new stroke event experienced by an individual patient If a patient has already been recorded in the AuSCR Database at your hospital you will be made aware of this once you have entered their details refer to section 10 Adding a New Patient Refer to the AuSCR data dictionary for definitions explanation and help notes on all the variables in the database To add a new episode 1 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 11 1 If the patient was transferred from another hospital or has a stroke while in hospital refer to the data dictionary for correct data and time entries on the different scenarios of admission information to ensure consistency 1 Type or use the calendar for 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 e Time of arrival to Emergency Department ED enter the time the patient arrived in the ED of
5. It is important to clarify with all patients guardians next of kin which variables they would like removed it is possible to keep only details about their stroke in the database while removing all personal and identifiable information about the patient The signing of the opt out form see Attachment 2 ensures that a record of the patient s request to be removed from the AUSCR Database remains on their medical file for all future admissions Thus the AUSCR office will request 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 anda copy faxed to the AuSCR office secure fax number on 02 8507 2531 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 asterix 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 labeled buttons are used throughout the AUSCR Database and require a left mouse click to activate AuSCR Hospital User Version 9 10 11 2010 4 Data are entered into the AUSCR Database using 1 5 Text boxes a blank white box which you type data in Before typing data you must ensure the cursor indicated by a flashing blac
6. Opt Off Request Te Removing Pe c from eis Australian Stroke AUSE Clinical Registry database Australian Stroke Clinical Registry Please send this form to the AuSCR office Hospitals should also retain a copy of this form 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 M tick the information that you would like removed from the Stroke Registry Personal information about me O Name L Title Mr Mrs etc L Medicare Number Ll Gender L Date of Birth Ll Aboriginal Torres Strait Islander status L Country of Birth L Language spoken Ll My address L My telephone number C My mobile number DL Name s of my Next of Kin and or Alternate Contacts O Telephone numbers s of my Next of Kin and or L Address s of my Next of Kin and or Alternate Alternate Contacts Contacts Ll Name of my GP Ll GP address O o GP Telephone number Information about my stroke and care received in hospital All of my personal information L Date of the onset of the stroke Ll Time of the onset of the stroke L Date of arrival to Emergency Department Ll Time of arrival to Emergency Department Ll Date of admission
7. data available in the AuSCR Database Therefore data in these reports have not been verified or checked by the AUSCR office and are for internal use only Table 18 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 refer to section 19 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 18 1 Select the Report Type from the 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 NO af Oo A dialogue box will open with an option to open or save the chosen Report Figure 18 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 Note If there is an error a new error window will appear Close the new error window and go
8. ssssssssssesess 65 Attachment 5 Example of User Request Form sse 66 Attachment 6 Example of Patient Contact Letter Post Discharge ssessssssss 67 AuSCR Hospital User Version 9 10 11 2010 2 1 Document Overview This user manual is designed as a guide for hospital staff required to access and enter data into the Australian Stroke Clinical Registry AuSCR 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 several steps to enter data first each patient must be created New Patient then each episode must be recorded Episode Details This manual will guide staff through each of these steps and also explain other user options such as printing reports and importing and exporting your hospital s data in and out of the AUSCR Database 2 Contact Details Further information can be found on the AuSCR website http www auscr com au or by contacting the AUSCR central data management office located at The George Institute for International Health in Sydney Assistance from the AuSCR office is available from the helpdesk Monday to Friday between 9am and 5pm Contact can be made via e Email admin auscr com au e Telephone 02 9993 4592 3 Background Information A PowerPoint presentation can
9. Click Ok button On the Options screen enter a strong password see below into the Password to open field 10 Click OK button d O po ND Important Note Strong password e Minimum of 10 characters e Complexity of characters use of non alphabetical and numeric mixed case characters e 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 also save a copy of each file in a local hospital computer directory set up for AuSCR and give it a unique name that will ensure creating new hospital extract files that have overlapping duplicate data are avoided For example the date range should be listed as part of the file name AuSCR Import Excel Data Screen To Import Data Currently data is uploaded by AuSCR office staff until a reliable version of the import file can be independently produced at the local hospital then a hospital user can import the file directly into AuSCR 1 Click the Data button on the navigation menu Select Import Excel button on the navigation menu The Import Excel Data screen will be displayed After copying data into the template Click the Browse button Oak ON Select the Import Template from the Choose File to Upload dialogue box Click open 7 Click the Upload button AuSCR Hospital User Version 9 10 11 20
10. Click the Complete and Lock button located at the bottom of the page will no longer be able to be edited Important Note Only a Superuser or Project Team Administrator can unlock a locked i e Complete episode AuSCR Hospital User Version 9 10 11 2010 29 14 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 Project Team Administrator 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 The patient episode requested for deletion will automatically be added into the Delete Episode List accessible only to Superusers and Project Team Administrators at the AuSCR office The Superuser or Project Team Administrator from the 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 Project Team Administrator from the AuSCR office Once deleted it ca
11. OocugHga Separation Discharge Information han kaa a e Miri nio pound iil Patient Deceased g No Yes date of death COO dd mmvyyyy Estimated date Discharged Alive 1 v a Date of discharge L ILYEJLICILILILI ddimmiyyyy Estimated date b Discharge E Hospital J Home with support destination mode E Rehatbititationtinpanenty CI Home without support LJ Low level Residential Care C Transitional care services CI High level Residential Care J Died in hospital L Other C Discharged with antihypertensive agents O Yes L No LI Unknown d isthere evidence that a care plan outlining post discharge care in the O Yes C No community was developed with the team and the patient and or family f if patient has severe aphasia or cognitive impairments C Not applicable Z Unknown Form completed by LIDCOUOO OOOO Dae LI YE JL MEL contact Number TELLE EIC IE E 1E weaied 19 June 2009 3 AuSCR Hospital User Version 9 10 11 2010 64 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 hospital user manual AuSCR Hospital User Version 9 10 11 2010 65 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
12. Postcode AQBAOCOCOCOOO see PECIAE TEL LLL Phone Number e 9 LE dH eS Te E e Mobile Number NEMA LJ EIE IE TET I Relationship to participant Sow eee General Practitioner CLLEEEEELEEEEEEEEEELELOO iN First Name Tor AC COCO ustNem SAAD OOOO COLO srect Address GIOIA DLS A OOOO iub creer Sr n Tora net T 3C X CT 34 0 I LICL Post Code BJETESEUE E ETC UE E State ESAE JL E ECL created 19 June 2008 AuSCR Hospital User Version 9 10 11 2010 60 GP Telephone Number LJ O 0OOOO0OO0COO0O0OC Mobile Number LAXE JC TL ICICILICI Admission Information p Bebes l u Date of arrival at Emergency Department PEADRA 45m yyw Estimated date mn Time of arrival at Emergency Department Date of stroke onset 0 A Estimated time Estimated date L1 Estimated time e Time of stroke onset Date of admission DIE o E veo IOI fad mmsyyyy Was the patient transferred from another hospital O Yes V No C Unknown Did this stroke occur while the patient was in hospital L1 Yes No LI Unknown O Yes Vf No LI Unknown Able to walk independently on admission li e may include walking aid but without assistance from another person ls there documented evidence of a
13. Stroke Clinical Registry collects data from participating hospitals across Australia using an online web tool Hospitals can use the online tool to Store their own patients data provide clinicians with downloadable reports summarising their patients data allow hospitals to export their data for local analyses and provide annual performance reviews newsletters and publications 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 button to access the online web tool and database The Australian Stroke Clinical Registry office staff are available on 02 9993 4592 during AEST business hours arch AuSCR Site Map Contact Us Tight 2009 All right reserved AUSCR Find out about AuSCR our governance structure and sponsors Read through our FAQ section and browse our Policy Documents and Reports read more Se Download Brochure Registry Login CLICK HERE Click here Consortium Partner ite iecom Group Username Password Remember me Forgot your user name and or See Note under point 5 ssword Please email admin auscr com au AuSCR Hospital User Version 9 10 11 2010 11 9 Navigation Menu Once you have logged in the AuSCR Database Home page
14. 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 The George Institute for International Health affiliated with the University of Sydney In your area the Stroke Registry is managed at name of hospita name of local investigator What information is collected when and by whom In hospital After you have agreed to participate your treating specialist and or nursing staff will complete the form that contains your details during your time in hospital This form includes the following information your name Medicare number date of birth hospital identification number your country of birth name of the hospital your preferred langua
15. an individual may be forthcoming from your participation in the Registry Will this affect your care No being involved in the Stroke Registry will not affect the way your treating doctors and stroke team approach your treatment or long term care 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 TGI PO Box M201 Missenden Road Sydney NSW 2050 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 asked 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
16. au 17 AuSCR Acute Data Collection Form The Acute Data Collection Form is a hard copy of the AuSCR Database Acute Data Collection Form See Attachment 3 is available for e hospitals that are not entering data directly from the medical record into the AuSCR Database or hospitals experiencing technical difficulties using the AuSCR Database e hospitals that do not have the capacity to enter data into the AuSCR Database AuSCR Hospital User Version 9 10 11 2010 34 Obtaining Acute Data Collection Forms Forms can be obtained by contacting the AUSCR office by email admin auscr com au or telephone 02 9993 4592 The AuSCR office can send the forms to you by email as a PDF document bymail when contacting the office provide a name and mailing address where the forms can be sent along with the number of forms required Downloaded directly from the Database from the New Patient screen To download a copy of the 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 Figure 17 1 Click on the hyperlinked Download paper based hospital data form The Acute Data Collection form will be displayed which can now be printed Using the 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 perso
17. 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 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 below the entered date should be clicked Notes for recording times The format used for time is always the 24 hour clock with a colon automatically inserted to separate hours and minutes hh mm Table 11 1 provides hints for recording time If an exact time cannot be recorded i e not in the chart or proxy family does not know 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 perform a calculation or express a time as Exact If a time cannot be clearly determined use the following guidelines Table 11 2 for estimating times in conjunction with the time the note was recorded or the time of arrival if not noted As the last resort if a time is unknown enter 99 99 Table 11 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 AuSCR Hospital User Version 9 10 11 2010 20 Table 11 2 Guidelines for Estimating Times Description o
18. 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 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 Regisiry project has beenapproved DIRS auis cnt met comis eset 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 do not wish to be O contacted after discharge and asked about how am managing known as follow up Patient NAME isos cie o reise nouns SEA SKe n nua des vin Nan e drain NAMES Date of Birth Phone Mobile contact eseeese Signature uncis eaa e es nia senos euet UU ERE CR Bate zou ane ente AuSCR Information Sheet for Patient and Relatives and Consent Finalv7 31052010 AuSCR Hospital User Version 9 10 11 2010 54 Attachment 2 Example of Opt out Form
19. 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 ERU lete Epi 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 Patent 2 14 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 FollowUp v e provides annual performance reviews newsletters and publications Please contact admin auscr com au to enquire about participating in AuSCR 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 If you are experiencing any difficulties or would like to have AUSCR help notes sentto you by email please contact admin auscr com
20. or by using an embedded calendar to select the date The use of the calendar is the preferred option to reduce errors AuSCR Hospital User Version 9 10 11 2010 5 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 lt to move back by one month tomove forward by one month gt gt to move forward by one year X to close the calendar e Eg lt lt lt January 2000 gt gt gt x Sun Mon Tue Wed Thu Fri Sat 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Q amp hw e Cc Today Episode An Episode provides the details of 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 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 is not a problem Saving Data Pressing Enter at any time during the data entry assumes that all variables have been completed and the save function is actioned Variable Definition All variables collected are defined in the AUSCR Data Dictionary Attachment 4 Variable definitions and formats where p
21. 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 required AuSCR Hospital User Version 9 10 11 2010 26 Death Information 1 Click the Patient deceased box if applicable This will expand the Death Information section to display additional data entry fields Figure 11 5 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 Note If a 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 we do not contact family members and request for them to complete a 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 did not complete any of the required fields in the admission screen when you click save an error message will alert you however if you ignore it and exit the screen none of the information will be saved Once all of the data has 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 If the episode is comp
22. the raw data directly entered by 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 range that AuSCR office has verified the data it is your hospital s responsibility to check and clean the raw data To export data 1 p NM Poa Sy Click the Data button on the navigation menu Click the Export Excel button on the navigation menu The Export Excel Data screen will be displayed see Figure 19 1 Type in or use the calendar to select the date range desired Click the Export button A dialogue box will open with an option to open or save the file Clicking the Open button will open the file for viewing and saving Clicking the Save button will allow you to save the file to a folder in your computer Figure 19 1 Data Export AuSCR Hospital User Version 9 10 11 2010 39 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 m To admission date AuSCR Hospital User Version 9 10 11 2010 rm Important Note The data will be exported to an Excel spreadsheet with a series of worksheets for some of the variables from the Database i e hospital users only have the acute hospital data available for export These
23. the Hospital which has been electronically generated on the emergency face sheet If this time is not available use written documentation by nursing or ambulance staff If there is conflicting data use the earliest time recorded e Onset of stroke date e Onset of stroke time e Date of admission to hospital Enter the date the patient arrived in the ED of the First hospital In some cases i e those patients who are observed in Emergency before the decision to admit is made 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 hospital the two may differ if the patient arrives close to midnight and is actually admitted the following day 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 AuSCR Hospital User Version 9 10 11 2010 19 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 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 below the
24. to be able to log in to the AuSCR Online Tool required field Title Name Position Hospital Email Phone Signature Access Request for Tick appropriate box L Hospital Administrator L Hospital User J 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 02 9993 4592 C The George Institute Fax 02 9993 4502 PO Box M201 Missenden Rd SYDNEY NSW2050 Office Use Only Date received Date created User name Password assigned User Request Form 28 july v4 AuSCR Hospital User Version 9 10 11 2010 66 Attachment 6 Example of Patient Contact Letter Post Discharge a ET wa HOSPITAL LETTERHEAD Ai ww EB Australian Stroke Clinical Registry Date Dear NAME We wish to inform you that your hospital hospital name is participating in the Australian Stroke Clinical Registry AuSCR which 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 TIA Because you or your family
25. to hospital DL Whether you were transferred from another hospital DL Whether or not this was your first stroke DL whether the stroke occurred while you were in hospital DL whether you were able to walk when you were Ll Hospital codes that define your diagnosis medical admitted to hospital condition and any complications or procedures L if you were treated in a Stroke Unit Ll Type of stroke L Date of discharge from hospital Ll Discharge destination O i you were given a careplan at discharge O if you received an Antihypertensive agent at discharge L Date of death if applicable Ll All of my stroke and hospital care information C Being contacted and having follow up details recorded in the Stroke Registry eg support services who live with and my quality of life O All ofthe above information Patient s Name Name of Hospital 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 PO Box M201 Missenden Road Sydney NSW 2050 Australia Fax Attention AuSCR 02 9993 4502 Opt off FormV4 250609 AuSCR Hospital User Version 9 10 11 2010 55 Attachment 3 Example of Acute Data Collection Form F d DATA COLLECTION FORM AUSCGH Australian Stroke Clinical Registry Please complete the form Retum form to AuSCR Office via Neatl
26. will appear with the navigation menu displayed on the right hand side Figure 9 1 The navigation menu then appears on each page while you are logged in Table 9 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 9 1 Navigation Menu AJ T i ps d H Welcome Hospital Australian Stroke Clinical Registry User Account E ie hospuser rns Patient a New Patient Search Patient Welcome to the Australian Stroke Clinical Registry The Australian Stroke 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 Ji people affected by stroke E Table 9 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
27. 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 then 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 the following table Worksheet Linked Worksheet Link Hospital Patient Record Hospital Id Hospital Follow Up Patient Hospital Id Person Patient Record Person ld Person Follow Up Patient Person Id Patient Record Patient Address Patient Record Id Patient Record Patient Contact Emergency Contact Id Alternate Contact Id GP Contact Id Follow Up Patient Follow Up Patient Follow Up Patient Id Address Follow Up Patie
28. 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 purposes only Data Import Excel Allows for XML import from hospital Hospital database to AUSCR Administrator Export Excel Allows for export from excel Hospital spreadsheet of raw data from your Administrator hospital input for manipulation AuSCR Hospital User Version 9 10 11 2010 12 10 Adding a New Patient To add a new patient 1 Click the New Patient button on the navigation menu and the New Patient page will be displayed Figure 10 1 2 Type the patient s First Name Last Name and Date of Birth into the appropriate text boxes Important Note These fields are mandatory as indicated by the next to them 3 Type in the patient s Medicare Number if known 4 Do not complete the Individual Healthcare Identifier Please leave blank 5 Stop and 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 6 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 7 Once the new patient has been saved a Patient Record page will be displayed Figure 10 2 Important Note The patient s name date of birt
29. 0 16 Request to Opt Out data from AuSCR sssssssssssseseeeeneeenenrrennnnn 31 17 AuSCR Acute Data Collection Form ssssssseseeeeeenenenennn ens 34 18 Downloadable Reports ssssssssssssesssssseeenee eene rennen nrnnrnn nennen 37 19 Data Export function Hospital Administrator Only sssseseessssss 39 20 Importing Data esssssesseseeeeneenneeennnnennn nennen kaaba nennen enn herren nens 41 21 FONOW Io 46 22 Err SGre Sss eere eee cente Fee eene e eaaet r aee xen edant ea eeu eiaa REEL PEENES 46 23 Quality Assurance Data Management Processes s sss 48 24 FECA DAGK RM 48 25 Frequently Asked Questions sssssseseeeeeneneenn nennen 48 Appendix 1 Technical specifications for Import file data entry esssse 51 Attachment 1 Example of Patient Information Sheet ssssseeee 53 Attachment 2 Example of Opt out Form sessssssssssseeeeee enne 55 Attachment 3 Example of Acute Data Collection Form essen 56 Attachment 3a Example of Correctly completed Acute Data Collection Form 59 Attachment 3b Example of Poorly completed Acute Data Collection Form 62 Attachment 4 Data Dictionary provided to your Hospital
30. 10 45 AUSCE Australian Stroke Clinical Registry Administration z Import Excel Data User Account X Patient a Import File Bowse O New Patient The following link provides an example a panem ofthe formatto use for importing excel Up m Description data into AUSCR Please also refer to comments under each column s heading for a description of what constitutes valid data a Download the template with sample data here Excel led Excel List Upload Export Excel Important Note If there are any errors the Import Excel Data screen will show the message FAILED Data was not uploaded Please fix above validation errors and try again User can see which record was problematic and why When the import is successful the screen will indicate this to the user SUCCESS Data was successfully uploaded 21 Follow up Approximately three months after admission to hospital patients will be followed up by AuSCR staff via telephone and or postal questionnaire They will be asked to complete questions about their current living circumstances and health status including questions about their quality of life The EuroQol EQ5D is used for adults and the PedsQL for those aged less than 18 years to assess quality of life At this time the AUSCR project staff will again explain to each patient their right to opt out any or all information in the registry and or their ability to refuse to participate in the follo
31. AUSCE Australian Stroke Clinical Registry Hospital User Manual November 2010 Version 9 Table of Contents 1 Document Overview sssssssssssssssssssseee eeeeaaeaeeeeeeeeseceaaeeeeeeeeseecceeeeeeeeseegeaaaes 3 2 Contact Detalls iz HT 3 3 Background Information ccccccceceeeeeeeceeeeeeeeeeeeeeeaeeeeeeeeseseaaeeeeeeeeseeeceeeeeeeeeeeeeeeaas 3 4 The Opt Out Consent Model ccceccecceeceeeeeeeeeeeeeeeeeeseeeaaaeeeeeeseeecaaeeeeeeeeeseeenanaeeees 3 5 General Information about the AuSCR Database 000 eee ceeeeseeeeeneeeeeeeeeeeeeteeeeeneaas 4 6 How to Obtain a Password ccccceceeeeeeeeeeeeeeeeeeeeeaaeeeeeeeeeeseaaeeeeeeeeeeeeccaeeeeeeeeeeenaaas 7 7 How to Change your Password cccceecceeeeeeeceeeeeeeeaeeeeeeeeeeseaaeeeeeeeeeeeeccaeeeeeeeeneenaas 9 8 Eerola Nare IV EE E TE m 10 9 Navigation M nUitssssinidieie ncn r EEE Ea NRE aS 12 10 Adding a New Patient ccccccceeceeeeeenneeeeeeeeeseceaeeeeeeeeseseaaeeeeeeeeseecaeeeeeeeeeesennaaees 13 11 Adding a New Episode irice eiis ianari aaea danie anida 19 12 Searching for a Patient Edit Patient c ccccceeeeeecceeeeeeeeeeeeeeneeeeeeeeeeeeeneaeeeeeeentees 28 13 Locking an Episode ssssssseseeeeeeneen mener nnne nennen 29 14 Request Deletion of an Episode sessssseseeeeeeeeeeeeeennnnnenn nns 30 15 Request Deletion of a Patient Record ssssssssssssseeneeeeenennn 3
32. Number HOODOO Relationship to participant l LILI I 1 43 E3 General Practitioner GP First Name IIL OOI I GP Last Name Street Address Post Code Suburb L Country GP Telephone Number OOOO GP Fax Number I AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 clean 2 AuSCR Hospital User Version 9 10 11 2010 57 Patient Name DOB 1 Hospital Admission Information Date of arrival at Emergency Department Accurate Estimate Time of arrival at Emergency Department Accurate Estimate stroke onset CIOIL O Accurate Estimate f stroke onset l O Accurate Estimate admission COL CLIL L Accurate Estimate Was the patient transferred from another hospital LJ LJ Unknown Did this stroke occur while the patient was in hospital Unknown Able to walk independently on admission Unknown
33. RACA totam STOTOTOTO T 5T T 1E Date of Birth I VE EC YE JL JL TL easy Gender Male 7 Female contyorbinh Pre e prep p qe T 1C JE JC LX JE JCICILICICIE EET Language spoken FEIN GALS OOOO Interpreter needed Yes 2 fio Is the patient of Aboriginal and or Torres Strait Islander C Aboriginal but not Torres Strait Islander origin origin CI Torres Strait Islander but not Aboriginal origin C Both Aboriginal and Torres Strait Islander origin ether Aboriginal nor Torres Strait Islander origin created 19 June 2009 1 AuSCR Hospital User Version 9 10 11 2010 59 OSCAR roses due acd ll KXjHH Emerg en A Contact First Name Se CCC Oe LCL LIII ILICE IDE EET tastName CILE EGAL E IL IL IC ILL JL JC JC JL JC AC AC AC JC 4c LLL 1 1L DROID Address type vf Home C Business Other SEE p AT LIENT ST KER Street Address LL LL EIL JL LAC LC EC JC JL 3L JC JC 4C JC C ILC C 1E TL Y Suburb MENNEERBERENEERERRREERENEENENENBENNEN Postcode OOOOOCOOCOOO sete NAKROOOCOOCO Phone Number L JL OOOCHOOC Mobite number COOCOOOHOOL OOOO Relationship to participant IPIE TT TT DEET IET E Alternate Contact FirstName OKIE aoe DEEEEEYTETEEPREED ij DODO wit RIRDIEBSIOOOOOOOOOooOoOOoOoOoooOooOo LEXIEXIEEELELEI nanesem D nem seem C Ger Street Address DIOL AA ea DM Led scrLelteteltr 3 3 4L 4L 4c 4 34 4L 1 Suburb Free vLex VIL TEETeSTE TE TEC YE C 3C JEJE TC ICI IC
34. al Record Number Important Note This is a mandatory field 3 Select the Gender if the title selected is Dr or if the title is unknown Important Note For all other titles the gender cannot be altered 4 Type in the Phone Number including area code and Mobile Number Important Note 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 5 Select the Aboriginal Torres Strait Islander origin from the drop down list 6 Select the Country of Birth and Language Spoken from the drop down lists Important Note 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 Interpreter Needed box to mark it with a tick AuSCR Hospital User Version 9 10 11 2010 14 Important Note This box cannot be marked if English is selected as the Language Spoken Figure 10 2 Patient Record Page Personal Information Patient Record Personal Information Jane Doe Name Please Select v Title Hospital Medical Record Number Gender Phone Number Mobile Number Is the patient of Aboriginal Torres Strait Islander
35. arge care in the community was developed with the team and the patient and or family AuSCR Hospital User Version 9 10 11 2010 25 Table 11 3 Discharge Destination Mode List Discharge Destination Mode Explanation of where the patient is discharged to Hospital A different acute hospital or palliative care hospital 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 entirely alone Home without supports Living at home with some support structure 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 Important Note If Died in hospital is selected the Death Information section must be completed Figure 11 4 Discharge Information Section Expanded Discharge Information v C Accurate Estimate Please Select v Please Select v Please Select v Date of discharge known Date of discharge Discharge destination mode Discharge on Antihypertensive agent Is there evidence
36. at any time during their stay e Type of Stroke Important Note If Type of Stroke selected is Ischaemic the following question will appear e Ifan Ischaemic stroke did the patient receive intravenous Thrombolysis tPA e Cause of Stroke AuSCR Hospital User Version 9 10 11 2010 22 Important Note modified TOAST criteria should be applied to determine if the Cause of Stroke is known or unknown Cause would be Known if Cause would be Unknown if large artery atherosclerosis cause cannot be identified cardioembolism two potential causes are present but small vessel occlusion itis unknown which is likely to be the cause stroke of other determined etiology evaluation is incomplete elicit drug use metabolic disorder intervention post operative ICD10 Principal Diagnosis Select a stroke ICD10 code from the Principal Diagnosis drop down list If 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 ICD10 code Medical Condition Enter an ICD10 code for the Medical Condition s that is are available from the Medical Record into the drop down list the system will attempt to auto com
37. ation Alert AUSCE Australian Stroke Clinical Registry Thank you for registering with AuSCR You have 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 uat smsmt demo com 80 auscr 7 How to Change your Password To change your password 1 Click the User Account button on the navigation menu 2 Click the Reset Password button on the navigation menu and the Reset Password page will be displayed Figure 7 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 oap o Click the Update button to save your new password or click the Cancel button if you do not want to change your password 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 e Last name e Role in AuSCR e g Hospital User e Hospital name A new password will be emailed to you AuSCR Hospital User Version 9 10 11 2010 9 Figure 7 1 Reset Password Page AUSCE Australian Stroke Clinical Registry Welcome tname Home User Account Reset Password Reset Password Pa
38. back to the original window to fix your errors Additional detailed annual report of verified data and case mix adjustments including follow up data with national and state comparisons will be provided by the AuSCR Management Team AuSCR Hospital User Version 9 10 11 2010 37 Table 18 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 Stroke Type by Age Stroke Type by Gender Patients per Month Figure 18 1 Reports Page AUSCHR Australian Stroke Clinical Registry Select Report 1 Patient Episode Totals v Report Type 2 pun Start Date 3 pu End Date Generate Report Figure 18 2 Report Dialogue Box AuSCR Hospital User Version 9 10 11 2010 38 W File Download Do you want to open or save this file x Name patientCharactReport xls 25 Type Microsoft Excel Worksheet From uat smsmt demo com v Always ask before opening this type of file While files from the Intemet can be useful some files can potentially ham your computer If you do not trust the source do not open or save this file What s the risk 19 Data Export function Hospital Administrator Only The AuSCR Database has a data export function This function allows for the export of
39. be accessed electronically by contacting the AuSCR office or accessing the online version from the website www auscr com au The presentation provides an overview of the AuSCR project and includes information on the purpose governance data collected and benefits of participating in AuSCR First time users are encouraged to view the presentation prior to accessing the AuSCR Database 4 The Opt Out Consent Model For AuSCR to ensure quality data meticulous attention must be given to ensuring that complete data are collected on all patients and that all eligible patients with stroke are included in the AUSCR Database If AuSCR collects an incomplete set of patients from a hospital strong biases may occur and the usefulness of the data for the monitoring and planning of health care delivery is limited To achieve this and to include as complete set of patients as possible AuSCR uses an opt out consent model This means that all patients admitted with a stroke or TIA at your hospital should be entered in the AuSCR Database unless they their parent guardian or next of kin formally request not to be included To ensure informed consent and in line with the ethics approval at many sites an information poster and brochures describing the purposes of AuSCR are available AuSCR Hospital User Version 9 10 11 2010 3 on the stroke and general medical wards at each participating hospital The brochures outline the purposes of the registry and
40. ct and local file Encryptfile management Import via website or send encrypted file to AuSCR Office Hospital level processes Checks hospital file integrity amp data formats Saves backup of registry data Uploads file Checks data have been imported Notifies site that data are imported Routinelogic checks amp missing data data quality reports Enter missing episode data Setting up Initially clinicians need to contact the appropriate local business managers and IT department managers to discuss the IT requirements Resources to establish hospital extracts needs to be addressed locally and can be justified in terms of reducing clinician time needed for data entry AuSCR office will provide supporting technical documentation outlining the specific data requirements for the AuSCR Import process Since it is important that all patients with stroke admitted to a hospital or who experience an in patient stroke are entered in the AuSCR Database careful selection of filters to create a hospital extract for data importing is needed For example this might be based on key words in a provisional diagnosis and or AuSCR Hospital User Version 9 10 11 2010 42 limiting the filter for particular Medical Units No set of filters will be perfect so some manual scrutiny and assessing various options might be needed Once the best fit is found for ensuring the greatest coverage of eligible patients the extract can be
41. ct 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 anytime 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 If you would like to edit the stroke episode details after you have locked the episode of care you must contact the AuSCR office who are able to unlock the episode for you to complete your editing However once completed you must lock this episode again to permit follow up to occur AuSCR Hospital User Version 9 10 11 2010 49 There seems 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 e Discharge on 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 and or family If died in hospital is selected you must complete the Death Information that opens up in the webtool You should also make sure that Date of discharge is the same as Date of death What to I do for people who go home and were not given an information sheet It may be that a person has been admitte
42. d local executive and IT Support will be needed to establish the best method of extracting relevant data from your hospital systems The AuSCR office staff will work with your local Informational Technology department to assess the best solution for importing data from your systems By enlisting the support of local IT Infrastructure and Resources the AuSCR Hospital User can request an extract of data from the local Patient Administration System that can be imported directly into the AuSCR Database via the Internet The local Hospital User can choose to import all data or only a portion of the data The Hospital User local AuSCR Champion and or Principle Investigator can choose what data are to be imported and what data are to be manually entered At all stages security of the data is ensured A summary of the processes for establishing and using the import data options is outlined below in Figure 20 1 Figure 20 1 Summary of the processes for establishing and using import data solutions for AuSCR AuSCR Office Testing of import files in Hospital IT amp local AuSCR Local AuSCR champion E beca Uds sies champion Download report for Re DE ori A dite Agree business scope selected period gy Choose amp test appropriate Verify cases add extra report filters cases Data range function Pasteinto AuSCR EXCEL Identification of patients template if not already Establish process for routine extracted into this format data extra
43. d and discharged without receiving an information sheet It is important that everyone receives an information sheet and so these 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 such a letter is attached in Attachment 6 AuSCR Hospital User Version 9 10 11 2010 50 Appendix 1 Technical specifications for Import file data entry Data Source Commonly the data is sourced from the local Patient Admission System PAS A query is used to extract a cohort of stroke patients This candidate list may contain non stroke patients the list may also miss stroke patients If necessary a clinician would 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 a Microsoft Excel 2003 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 Import Form The order of the coloumns 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 coloumn attribute has specific data type text o
44. ddresses can be edited in the table by clicking directly on the data to be changed and altering it as necessary Addresses can also be deleted by clicking the Delete link to the right of the corresponding address A Warning message will display once the Delete link is clicked asking you to confirm that you want to delete the address Click the Yes or No button to confirm or cancel the deletion Figure 10 4 Patient Address Table Address Street Address Row Mailing Type Suburb State Postcode Country 123 George Sth 1 V Home Sydney NSW w2000 Delete Australia v l Mailing Address Home Address Type Street Address Select v Suburb State Postcode Please Select Country AuSCR Hospital User Version 9 10 11 2010 16 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 at least two contacts must be recorded in addition to the patient s own address to avoid loss to follow up 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 selecti
45. des 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 Important Note To remove a code from the list box below the Add button select the code in the list box then click the Delete button AuSCR Hospital User Version 9 10 11 2010 24 Discharge Information Figure 11 3 Discharge Information and Death Information Section Discharge Information r Date of discharge known Death Information E Patient deceased Activity Status ACTIVE Completion Status INCOMPLETE 1 Click the Date of discharge known tick box if applicable This will expand the Discharge Information section to display additional data entry fields Figure 11 4 2 Type in or use the calendar to select the Date of discharge and indicate whether the date is Accurate or an Estimate by clicking one of the corresponding radio buttons Important Note If patient died in hospital 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 11 3 Important Note The following two questions below will not appear if Died in hospital is selected as the Discharge destination mode e Discharge on Antihypertensive agent e Is there evidence that a care plan outlining post disch
46. describe how patients may opt out of being included It is the responsibility of the treating hospital to provide the Information Sheet to all patients This information sheet clearly explains the AuSCR project and how patients may opt to have some or all of their data removed from the AuSCR Database The process for providing this information to patients within your hospital should be 5 All patients or their relatives are provided with a copy of the AUSCR information sheet the version must be the version approved at your hospital See Attachment 1 This may be provided in your ward s admission pack 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 the information sheet should be given to the parent guardian Where a patient lacks competence to consent the information sheet should be given to their next of kin It is important to clarify that patient guardian or next of kin may request to remove or opt out any information at anytime and that this right does not end on discharge from hospital section 16 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 See Attachment 2
47. e 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 AuSCR Information Sheet for Patient and Relatives and Consent Finalv7 31052010 AuSCR Hospital User Version 9 10 11 2010 53 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 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
48. es and conformity with variable definitions will also be assessed during this site visit which is anticipated in the first year of participation when the first 50 cases have been entered and then bi annually unless concerns about data quality have been identified 24 Feedback AuSCR is a new project and your feedback is valuable as this will assist in further improvements to the Database and registry processes and procedures AuSCR will be scheduling feedback one week following initial training and one month following commencement of data collection using a structured questionnaire As required please email any other feedback to admin auscr com au 25 Frequently Asked Questions What do do if the same person is entered twice 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 rather than creating a duplicate record for the same person If the same person is entered twice because incorrect data has been entered in one of the records you can request that the incorrect record to be deleted following the steps outlined in section 15 of this manual What do do if don t know the ICD10 code The ICD10 codes must be obtained from the Medical Records department following completion of coding AuSCR Hospital User Version 9 10 11 2010 48 What do do if
49. ew the patient details To edit the patient details click the Edit button at the bottom of the page 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 Note You will only be able to search for and see patients associated with your hospital Episode numbers are not sequential by date of episode of stroke but by date of data entry If the episode is locked the episode cannot be edited and the Edit button will not appear A request has to be made to the AuSCR office by email to admin auscr com au to unlock the episode so the episode can be edited AuSCR Hospital User Version 9 10 11 2010 28 Figure 12 1 Patient Search Page AUSCP PE 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 13 Locking an Episode The AuSCR Database allows users to lock an episode and hence prevent it from being edited All episodes must be locked once completed 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 Id 3 4 This will change the Completion Status of the episode to COMPLETE and it
50. f 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 AuSCR Hospital User Version 9 10 11 2010 21 Figure 11 1 Admission Information Section Admission Information Date of arrival to Emergency Department enter 01 01 1900 if not applicable C Accurate Estimate Time of arrival to Emergency Department hh mm 24hr clock enter 99 99 if not applicable C Accurate Estimate Onset of stroke date C Accurate Estimate Onset of stroke time hh mm 24hr clock C Accurate Estimate Date of admission to hospital C Accurate Estimate Unknown Was the patient transferred from another hospital Unknown Did this stroke occur while the patient was in hospital Was the patient able to walk independently on admission Unknown i e may include walking aid but without assistance of another person Is there documented evidence of a previous stroke focal Unknown i neurological signs persisting for more than 24 hours required Clinical Information Figure 11 2 1 Select the appropriate option from the drop down list for each of the following questions fields e Was the patient treated in a Stroke Unit
51. finalised which can then be used to populate the AUSCR Import Template see below AuSCR office will coordinate with local IT resources to test the import file and feedback the necessary specifications to facilitate the data import To maintain Information Security Privacy during the initial stages of testing the Import file is transferred via email to the AUSCR office This file is encrypted to secure the information Refer to Encrypting MS Excel Workbook version 2003 for transmitting Stroke Data to AUSCR section below After testing is completed and a workable version of the Import File can be independently produced at the local hospital the hospital user can import the file directly into AUSCR Compatibility To maximise compatibility a prespecified Microsoft Excel 2003 file can be downloaded from the AuSCR Database by a hospital user logged into AUSCR This file is a formatted template for data import This template has several requirements for successful importing of data into AuSCR Each coloumn has a specific data type or has a set of predefined values compatible with METeOR standards Mapping data from local Patient Administration System to the AuSCR template Some of the predefined coloumn values in the AuSCR template need to be mapped for successful data import These mappings are compatible with MeTEOR standards which most hospitals already use in the Patient Administration System AuSCR office staff will work directly with l
52. ge your address type of stroke medical treatment and care in hospital your telephone and or mobile number complications if any contact details of your next of kin or health living arrangements after discharge from 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 information systems so we know how well you have recovered After discharge As a participant of the stroke registry you 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 yourname support that you have received since leaving date of birth hospital address If after discharge you need more care current health condition rehabilitation or are admitted back to living arrangements hospital information about your ongoing care 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 who have a security password to open the database Onc
53. gin L1 Both Aboriginal and Torres Strait Islander origin _ Neither Aboriginal nor Torres Strait Islander origin Acute Data Collection Form v3 1 17082010 AuSCR Hospital User Version 9 10 11 2010 56 Patient Name DOB Hospital Emergency Contact First Name l I LastName OCI LILI LILI ILI Address type Home Business C Other LDU IOI I State L JEJE E E JE JE E JEJE l obile Number Street Address Suburb Post Code Country O O I LT Phone Number Relationship to participan OOOO Alternate Contact First Name l l LastName OOOOOO0OQCOOOOC0O000C0O0CO0O0O0Q0O0000 Address type L Home L Business other Street Address Suburb Post Code on L L P L LI Country Phone Number OOOO OOL Mobile
54. h 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 correct details entered If you have noted a minor correction such as a change of case to a correctly 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 Project Coordinator for attention to 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 11 Adding a New Episode AuSCR Hospital User Version 9 10 11 2010 13 Figure 10 1 New Patient Page New Patient Download paper based hospital data form Personal Information First Name Last Name Date of Birth Medicare Number Individual Healthcare Identifier Royal North Shore v Hospital required m The Patient Record page is used to add further patient information under the headings Personal Information Address and Contacts Figure 10 2 To add personal information 1 Select the patient s Title from the drop down list Important Note Once title is selected the gender will appear automatically 2 Type in the Hospital Medic
55. ion settings For this workbook Password to open m Advanced File sharing settings For this workbook Password to modify Read only recommended Digital Signatures Privacy options Remove personal information from this file on save Macro security m E Adjust the security level For Files that might contain macro viruses and Macro Security specify names of trusted macro developers 3 Click the Advanced button to the right of the Password to open field Encryption Type iJ Choose an encryption type RC4 Microsoft Base Cryptographic Provider v1 0 RC4 Microsoft Base DSS and Diffie Hellman Cryptographic Provider RC4 Microsoft DH SChannel Cryptographic Provider RC4 Microsoft Enhanced 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 x Choose a key length 128 z MV Encrypt document properties TN AuSCR Hospital User Version 9 10 11 2010 44 4 This will open the Encryption Type dialogue box Select RC4 Microsoft Enhanced Cryptographic Provider v1 0 from the Choose an encryption type list Select 128 from the Choose a key length field Ensure that Encrypt document properties is checked
56. it Islander but not Aboriginal origin O Both Aboriginal and Torres Strait Islander origin p n Aboriginal nor Torres Strait Islander origin AuSCR Hospital User Version 9 10 11 2010 62 Emergeric cy Contact u Address type O street Address LJL E TE JL E EE YE YE 3E JC TE EC E ID ILC JL IL IC JC JC 4L 11 Suburb LJ JC EHE JC TC IEEE JC TC TC YE CICICILIC ICI IC E ICT Postcode LII TI TIGE see OOOOCCOOTO Phone Number CID Mobile Number KOO LI TY Y ELIT Relationship to parsoipant Alternate Contact CEEEEEEPEEBEREDEERDEBBRETIEG LITT TLILTIPTII First Name O OL First Name PARO aaa LILILILE E YET TET TET lastname CREA TE E IL CC JL JL JC JC JE JL JC EIC JC JC 4C LAE ILLU LILILEJE EY ELTE CILE Home O Business 5 Other Sepe rrr Last Name OO L1 Address type L1 Street Address DD Suburb L1 Post Code C L1 Relationship to partici Home ipant L JLJLILT E JEDDIC IE E EDDIE YECICICILHICIC OEC ICI LIJL TEE EICTY ETC LJ T EE ETC TD IDE IC GICILICICICICILUC ERNERERERBEEENEENRRERBEENNEENN LI III se CIT III JI Phone Number ODDO Mobile Number COO OOOO L1 Business LI Other General Practitioner Freee NCO OOOO EIE IEEE E E FETIILIIEIE LLLIEEEEEETTLIS usme COOOOOOOooooooooooooooooooo HECEEEBOTHETT T sre tates COOOOOOOOOOOOoOoooOooooooooog sem COOOOOOoooo
57. k 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 Eg Textbox Name Drop down lists a list of options which you select from These are white boxes which contain either a default option or the words Please Select and a small blue box with a down arrow To select an option click the down arrow and then click the option required 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 of the option you require Eg Please Select v Drop down JESSEN list name Mr Mrs Miss Ms Dr Mast Tick boxes a small white box which you click in to mark with a tick To remove the tick click in the box a second time In some instances where it is not applicable the tick box may be inactivated Eg Tick box name Iz Radio buttons a small white circle which you click in to mark with a dot If there is more than one radio button for a field only one button can be marked Clicking an alternative radio button for a field will unmark all other radio buttons for that field Eg Accurate Estimate Calendar Dates can be entered by either typing them in the text box
58. l User Version 9 10 11 2010 61 Attachment 3b Example of Poorly completed Acute Data Collection Form Incorrectly completed Data Collection Form DATA COLLECTION FORM AUSCH Australian Stroke Clinical Registry Please complete the form Return form to AuSCR Office via Neatly and legibly 4 Fax Write in black ink and press firmly s 188 850725317 Each question must be completed Or Place 7 in appropriate boxes Post AuSCR Office c o TGI PO Box M201 Required fields marked with must to filled Missenden Road Camperdown NSW 2050 JENNI pes Name Patient Information inii EE mE ITTHHYYM es JA e ILL YAT DIGAR Bee LI LT I ILILLLCLII test Name TETTE TE C TE JC IL TC JC ooo CEOCCOOCOCHOOOO Address type Home Business Other Street Address JIT OOOOOOOOOOOooo Suburb LIEGE ETC OOOO ooo Postcode D JL T ILI ID El stete LJ T LICET Phone Number OID Mobile Number ogogoro LI TY ILE Medicare No LIO COOCOOOOO Besetsies ECCE EE EE E Date of Birth LY VECILDYCILILIEI ddemm yyyy Gender Male Female county ofbith Al SITIO AT OOOOOoOonooooo M DOB 12 12 1921 First Name OO Language spoken E CHISHCTLELETETCIETEEEDEEIG Interpreter needed No ls the patient of Aboriginal and or Torres Strait Islander O Aboriginal but not Torres Strait Islander origin origin O Torres Stra
59. leted it must be locked by clicking the Complete and Lock button located at the bottom of the page See section 13 for further information Important Note When Completion Status shows Incomplete it means you can re enter the episode at a later stage and make changes to complete the data collection Figure 11 5 Death Information Death Information Iv Patient deceased m Date of death C Accurate Estimate required AuSCR Hospital User Version 9 10 11 2010 27 12 Searching for a Patient Edit Patient Important Note Users can only see patients from their own hospital To search for a patient 1 Click the Search Patient button on the navigation menu and the Patient Search page will be displayed Figure 12 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 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 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 Click on the hyperlinked Patient Name to vi
60. member were recently in hospital with a stroke the details have automatically been given to us We wish to contact you to clarify some details about the illness The information we collect about the treatment given in hospital will enable us to make contact with you at three to six months after the stroke so that we can assess the degree of recovery and any ongoing health problems This information is important to use as it will allow health care planners and doctors to improve the care that patients with stroke receive in hospital We have enclosed a copy of the AuSCR Patient Information Sheet which we hope you will take the time to read as it provides more details about AUSCR In brief it is a national initiative that is supported by The Australian Commission on Safety and Quality in Health Care the National Stroke Foundation and the Stroke Society of Australasia It has been approved by the Human Research Ethics Committee at local hospital Participation is entirely voluntary and any information you provide will be treated a as strictly confidential The AuSCR database has been specially designed to ensure that your name never be used to identify you to ensure that your privacy is maintained Neither your identity or personal details will be revealed in any publications or made available to outside organisations If you do not wish to participate please indicate this on the opt off form at the bottom of the Information Sheet and return it t
61. n responsible should sign and date the completed form Once the form has been completed the data can be entered into the AuSCR Database or it can be sent to the AuSCR office for data entry Good clinical practice guidelines must be used in completing the forms NHMRC National Statement with TGA annotation ICHGCP CPMP 135 95E6 Examples of both a correctly completed and a poorly completed Forms are attached Attachment 3a and 3b Completing the Acute Data Collection Form Write neatly and legibly with black ink Write Patient Name Date of Birth and Hospital name at the top of each page of the form this will ensure that the record remains intact even if faxed as separate pieces of paper 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 AuSCR Hospital User Version 9 10 11 2010 35 e If the information is not available write the reason next to the question e g to be obtained later not available e With estimated or unspecified times and dates use the rules for estimating times and dates that are outlined in the data dictionary e f 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 e Some hospital labels do no
62. nal information O Do not wish to be contacted for follow up Form completed by JL I JE d ILL ILL Date JL VE LC L ILL Contact Number IDI AuSCR ACUTE DATA COLLECTION FORM V3 1 17082010 clean 3 AuSCR Hospital User Version 9 10 11 2010 58 Attachment 3a Example of Correctly completed Acute Data Collection Form Correctly completed Data Collection Form Australian Stroke Clinical Registry pata COLLECTION FORM fi AUSCH Please complete the form Return form to AuSCR Office via Neatly and legibly Fax 02 8507 2531 Write in black ink and press firmly pa 1 Each question must be completed i Place Jin appropriate boxes Post AuSCR Office clo TGI PO Box M201 Required fields marked with must to filled Missenden Road Camperdown NSW 2050 Hospital Name Roa JOHNS ay HOSPITAL HEAVENS ViLLe C RJHH Dur HUI B009085 BLOGGS OSCAR M 12 Registry Street M Heavensville DOB 12 12 1921 2150 PaticntInformation Title IPSI TE ECCL JEJE LI seme DECIPI T I IEICEIHIEEIREREIERIEERERERR we iExESteteisi T HP ee LJ Te eds ODIO LY FOOD Address type d CI Business 7 Other SEE PATIENT STICKER sweet Address OOOO Suu IDOI Postcode J I T T states ASAOOOOOo Phone Number OVA EART Mobie numer EH E615 TTL 1E 1 i LJEXE YE EET Medicare No A
63. ng one of the options in the drop down list Important Note If Other Relative is selected an Other Relative text box will appear which should be typed in to specify 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 has been entered click the Save button at the bottom of the page to save the information on the Patient Record screen An Information page will be displayed showing all information entered for the patient Figure 10 5 AuSCR Hospital User Version 9 10 11 2010 17 Figure 10 5 Patient Contacts Section Contacts Emergency Contact Please Select v Title First Name Last Name Phone Number Mobile Number Please Select Relationship l Sameas patient home address above Home v 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 v Relationship sameas patient home address above Home v 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 v Country AuSCR Hospital User Version 9 10 11 2010
64. nnot be reversed 15 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 Project Team Administrator before the record is actually deleted To request the deletion of a patient episode ue Search for the patient to be deleted 2 View the patient to be deleted by clicking on the hyperlinked Name 3 4 Click the Yes button to confirm the deletion or the No button to cancel the Click the Delete button a warning panel will appear Figure 15 1 deletion If the Yes button is selected the Status of the patient will now appear as Inactive The patient episode requested for deletion will automatically be added into the Delete Deletion List accessible only to Superusers and Project Team Administrators at the AuSCR office The Superuser or Project Team Administrator from the AuSCR office will perform the actual deletion using the Delete Deletion List during scheduled data management processes AuSCR Hospital User Version 9 10 11 2010 30 Important Note Actual deletion can only be performed by a Superuser or Project Team Administrator Deleting a patient will delete all associated episodes linked to the patient Once deleted it cannot be reversed Figure 15 1 Delete Patient Warning Are you sure you want to mark the patient record for deletion 16 Request to Opt Out data from AuSCR A patient wh
65. nt Follow Up Patient Contact Emergency Contact Id Alternate Contact Id GP Contact Id Follow Up Patient Follow Up Questionnaire Follow Up Id 20 Importing Data The AuSCR Database has some options available for hospitals that would like to directly import data into the system An optional import data Excel formatted template can be downloaded from the AuSCR Database and used by hospitals to upload data and avoid manual data entry which may also help to reduce systematic data entry errors e g spelling of name etc This was developed to overcome the issues of variability in hospital information technology systems We have also developed a web service as another option for hospital staff who would like to upload data from their patient administrative systems into the AuSCR Database Nevertheless there are risks and pitfalls when data are imported from one system to another For example careful selection of filters is required to ensure only eligible patients e g new patients not already the system who have confirmed stroke or TIA are entered into the AUSCR Database Therefore at this stage only AuSCR office Superusers and Project Team Administrators have the authorisation AuSCR Hospital User Version 9 10 11 2010 41 to import data into the system from a spreadsheet Integration of web services is more complicated which will allow for direct streaming of data into the system Regardless of which option is nominate
66. o 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 AuSCR office staff 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 the request by the Hospital User followed by the confirmation by the Superuser or Project Team Administrator 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 16 1 4 Select the corresponding radio buttons of the item s the patient guardian or next or 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 16 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 16 3 8 The request will automatically be added to the Opt Out List accessible only to Superuser and Project Team Administrator at the AuSCR office 9 The Superuser or Project Team Administrator from the AuSCR office will perform the actual opt out using the Opt Ou
67. o us at AuSCR Project Office The George Institute PO Box M201 Missenden Road NSW 2050 If we have not heard from you within two 2 weeks we will assume that you are willing to have your details recorded If you have any questions concerns or complaints about AuSCR please contact the Project Coordinator on telephone 1800 673 053 or email admin auscr com au AuSCR Hospital User Version 9 10 11 2010 67 Any person with concerns or complaints about the Stroke Registry may also contact the Executive Officer of the relevant Ethics Committee on telephone or email email email comau Yours faithfully Cle SIGNATURE SIGNATURE Name of Patient s Primary Treating Physician Professor Craig Anderson Title AuSCR Chief Investigator Name of Hospital Enc Patient Information sheet AuSCR Hospital User Version 9 10 11 2010 68
68. obile Contacts Relationship Name Name Number Number annue Contacts Address I Contacts Suburb I Contacts State Contacts Postcode y Contacts Country Date of arrival to I Timeofarivalto ncaa or icio dido Onset of stroke Date of admission to emergency department emergency department time hospital p B W i Was the patient Did this stroke a patient Is there Was the patient treated in transferred from occur while the patient ms ieu Los documented evidence a Stroke Unit at any time another hospital was in hospital E d y ofa previous stroke during their stay I Did the patient I Type of stroke receive Intravenous Cause of stroke Thrombolysis ICD10 code ICD10 code ICD10 code ICD10 code Diagnosis Medical Condition Complications Procedures z E E ji Date of discharge Taie of discharge Discharge Discharge on a nanc op a known destination mode Antihypertensive agent P gp discharge care Deceased Date of death AuSCR Hospital User Version 9 10 11 2010 33 Figure 16 2 Opt Out Warning i Are you sure you want to opt out this person LAE Figure 16 3 Opt Out information saved AUSCH LEY woe NEZ Australian Stroke Clinical Registry Users Hospitals Welcome to the Australian Stroke Clinical Registry Merge Records Opt Out The Australian Stroke Clinical Registry AuSCR is collaborative national effort to
69. ocal technicians to ensure valid mapping of data from the local Patient Administration System To obtain the Import Template 1 Click the Data button on the navigation menu 2 Select Import Excel button on the navigation menu 3 The Import Excel Data screen will be displayed 4 To download the Import Template spreadsheet click the information n 5 In the yellow pop up message click the Download the template with sample data here link icon 6 The File Download dialogue box will pop up click save to save the spreadsheet AuSCR Hospital User Version 9 10 11 2010 43 Figure 20 2 Import Excel Data Screen AUSCE Australian Stroke Clinical Registry Administration Import Excel Data User Account Patient Import File Browse 6 New Patient The following link provides an example am ofthe formatto use for importing excel Description data into AuSCR Please also refer to comments under each column s heading for a description of what constitutes valid data Download the template with sample data here KCN Export Excel Encrypting MS Excel Workbook version 2003 for transmitting Stroke Data to AuSCR 1 Open the saved EXCEL file you wish to password protect and click Tools Options 2 This will open the Options screen click the Security tab Options View Calculation Edit General Transition Custom Lists chat Color International Save Error Checking Spelling File encrypt
70. oooooooCoocoocog rte OOOOOOOOOO see OOCOCOCOC LOCOS 5 O created 19 June 2009 AuSCR Hospital User Version 9 10 11 2010 63 GP Telephone Number LJ O 0OOOO0OO0COO0O0OC Mobile Number LAXE JC TL ICICILICI Admission Information p Bebes l u Date of arrival at Emergency Department PEADRA 45m yyw Estimated date mn Time of arrival at Emergency Department Date of stroke onset 0 A Estimated time Estimated date L1 Estimated time e Time of stroke onset Date of admission DIE o E veo IOI fad mmsyyyy Was the patient transferred from another hospital O Yes V No C Unknown Did this stroke occur while the patient was in hospital L1 Yes No LI Unknown O Yes Vf No LI Unknown Able to walk independently on admission li e may include walking aid but without assistance from another person ls there documented evidence of a previous stroke m i e focal neurological signs persisting for more than 24 hours o Yes No Li Unknown Clinical Information a ee eee MET NER INE T E RR REN E Was the patient treated in a Stroke Unit at any time during their stay Oo Yes C No L Unknown Type of stroke OTa w aes C Haemorthagic C Undetermined If an ischaemic stroke did the patient receive intravenous thrombolysis tPA Yes O No C Unknown Cause of stroke C Known F Unknown ICD10 code Diagnosis
71. ospital User if you are a Hospital Administrator 1 Click the Administration button on the navigation menu Click the Users button on the navigation menu Scroll down to New User button at bottom of the User List Click on New User button Figure 6 1 Complete new user details on User page Figure 6 2 Dapy Create a generic password The password must be longer than 4 and shorter than 9 characters and contain both letters amp numbers 7 Click the Receive Email tick box 8 Select Hospital User in 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 6 3 AuSCR Hospital User Version 9 10 11 2010 7 Figure 6 1 Creating New User Page User Username First Name Last Name Password Confirm Password Email iv Receive Email Superuser v Role required Figure 6 2 User Details Page example AUSCE Australian Stroke Clinical Registry LET User agathaf Username Agatha First Name Foilan Last Name mI Password CITT Confirm Password afoilan george org au Email Vv Receive Email Hospital User Role Royal North Shore v Hospital Q value is required required Ld AuSCR Hospital User Version 9 10 11 2010 8 Figure 6 3 Registration Alert Email From australian Stroke Registry admin auscr com au To AuSCR Admin Cc Subject Registr
72. ossible are consistent with the electronic National Health Data Dictionary METeOR http meteor aihw gov au content index phtml itemld 181 162 Where a METeOR definition does not exist we have used the definition from the National Stroke Foundation Audit AuSCR Hospital User Version 9 10 11 2010 6 6 How to Obtain a Password Each hospital will have a Hospital Administrator created by the AUSCR office The Hospital Administrator will then be 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 and email or fax it to the AuSCR office Contact the AuSCR Office to have a form sent either by email or fax 2 Once created a Registration Alert email will be generated with your username and password in an email back to you 3 You must change the generic password given to you when you first log in to the AuSCR Database The AuSCR office contact Email AuSCR Project Coordinator admin auscr com au Fax 02 9993 4592 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 2 Once created a Registration Alert email will be generated with your username and password in an email back to you 3 You must change the generic password given to you after you log into the AuSCR Database for the first time How to create a H
73. otect your personal information read more Latest News November 3rd 2010 Latest News Title AuSCR Newsletter November 2010 Issue 9 is now available Download Media Release November Newsletter EN Latest annual report 1800 673 053 com au Free Call me Patients amp Family Members Health Professionals Australian Stroke Clinical Registry A Figure 8 2 Login Page AUSCE Australian Stroke Clinical Registry Patients and Family Members Health Professionals HEALTH PROFESSIONALS Find information on the benefits of AUSCR to health professionals Learn how your hospital can participate in AUSCR read more Research AuSCR Contact RESEARCH Learn about the many benefits of AuSCR for researchers You wil also find links to Research Publications and Proposal submission guidelines read more Home 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 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 The Australian
74. p with A 606 Nationa Stroke Research Institute strokefoundation Fro Figure 22 2 Access Denied AUSCH Australian Stroke Clinical Registry Home Access Denied You dont have sufficient permission to perform this operation THE GEORGE INSTITUTE To gain access please contact admin auscr com au with your username and details of the task you are trying to perform In partnership with oue I Nationat Stroke Research Institute strokefoundation E sine y V THE GEORGE INSTITUTE AuSCR Hospital User Version 9 10 11 2010 47 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 to be undertaken 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 ICD10 discharge codes from the hospital patient administration system database with cases entered in AUSCR Database to ensure all eligible admission have been captured e random medical record auditing by the AuSCR office following a pre arranged site visit may also be undertaken to assess the accuracy of data The registry data collection process
75. plete 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 ICD10 code Medical Complication Enter an ICD10 code for the Medical Complication s that is are 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 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 Procedure ICD10 code Clicking the Add button will append the code to the list box under the Add button AuSCR Hospital User Version 9 10 11 2010 23 Figure 11 2 Clinical Information Section Clinical Information Was the patient treated in a Stroke Unit at any time during Unknown x their stay Please Select v Type of stroke Please Select v Cause of stroke Enter some value fo ICD10 Principal Diagnosis Please type in a new code if it does not appear in the list E E ICD10 code Medical Condition Please select or add co
76. previous stroke m i e focal neurological signs persisting for more than 24 hours o Yes No Li Unknown Clinical Information a ee eee MET NER INE T E RR REN E Was the patient treated in a Stroke Unit at any time during their stay Oo Yes C No L Unknown Type of stroke OTa w aes C Haemorthagic C Undetermined If an ischaemic stroke did the patient receive intravenous thrombolysis tPA Yes O No C Unknown Cause of stroke C Known F Unknown ICD10 code Diagnosis OocugHga Separation Discharge Information han kaa a e Miri nio pound iil Patient Deceased g No Yes date of death COO dd mmvyyyy Estimated date Discharged Alive 1 v a Date of discharge L ILYEJLICILILILI ddimmiyyyy Estimated date b Discharge E Hospital J Home with support destination mode E Rehatbititationtinpanenty CI Home without support LJ Low level Residential Care C Transitional care services CI High level Residential Care J Died in hospital L Other C Discharged with antihypertensive agents O Yes L No LI Unknown d isthere evidence that a care plan outlining post discharge care in the O Yes C No community was developed with the team and the patient and or family f if patient has severe aphasia or cognitive impairments C Not applicable Z Unknown Form completed by LIDCOUOO OOOO Dae LI YE JL MEL contact Number TELLE EIC IE E 1E weaied 19 June 2009 3 AuSCR Hospita
77. r has a set of predefined values compatible with MeTEOR standaras Data Entry Constraints The system requires as a minimum the following data 1 Itis 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 or Given or Christian name Last Name or Surname MRN local primary key identifier of the Patient in the Hospital PAS Date of Birth patient s date of birth 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 m m p qe 7 The First Name Last Name Date of Birth Medicare number Hospital Identifier and Admission date will create a new instance for the patient If a duplicate is detected during import processing the data will be updated to the database for that patient instance 8 Refer to the Data Dictionary for specific definitions of data values 9 Refer to the ImportSpecification xls for data specifications AuSCR Hospital User Version 9 10 11 2010 51 Data Mapping Refer to the spreadsheet ImportSpecification xls for specific instructions for each coloumn 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
78. t List during scheduled data management processes AuSCR Hospital User Version 9 10 11 2010 31 Remember e lf you have made a mistake or incorrectly entered a patient who did not have a stroke then you should Delete this case and not request for this person to be Opted Out e fa patient is happy to have their details in the AuSCR Database however does not want to be contacted again at follow up post discharge you should click the Do not Contact Patient at Follow Up box which appears beneath the discharge information screen and not request for this person to be Opted Out Important Note Actual opt out can only be performed by a Superuser or Project Team Administrator Opt Out once confirmed cannot be reversed Please re read section 4 the Opt Out Consent Model before proceeding with an opt out request AuSCR Hospital User Version 9 10 11 2010 32 Figure 16 1 Opt Out Page AUSCE Australian Stroke Clinical Registry Comments Select All Do not contact for follow up First Name LastName Date of Birth Medicare No Title E Gender Phone Number Mobile Number Aboriginal Tores y Country of Birth St Islander Language Spoken Interpreter Needed i Maili E B Address Mailing Address Address Address Street Address Suburb Address State Address Type Address Address Postcode Address Country i Li E E Mobi Contacts First Contacts Last Contacts Phone Contacts M
79. t 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 e 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 e Do not use white out Sending completed forms to the AuSCR office e You must contact the AuSCR office by email admin auscr com au or telephone 02 9993 4592 to inform them that you are sending them completed patient forms e Completed forms can be sent to the AuSCR office by Secure Fax 02 8507 2531 only for confidential information Scan and email to admin auscr com au Mail AuSCR Project Office PO Box M201 Missenden Road SYDNEY NSW 2050 Figure 17 1 Download Acute Data Collection Form AG Ir 5 R Welcome Superuser Logout Australian Stroke Clinical Registry Download paper based hospital data form Patient New Patient Personal Informatio Search Patient Follow First Name ep Report m Last Name Data Data Click on Dato of Birth hyperlink Medicare Number Royal North Shore Hospital here EPI CTI ESL Save Cancel AuSCR Hospital User Version 9 10 11 2010 36 18 Downloadable Reports Individual pre specified hospital reports are available to all hospital users via the AuSCR Database The reports may be generated at anytime and use the current
80. there are no contact details Enter No fixed address Homeless or Nursing Home in the Suburb field of the address Refer to 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 Print screen on your keyboard to capture the error message displayed on your screen 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 obtain a password 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 How do Il edit information in the AUSCR Database It is not possible to edit any errors or add anything to the Patient Information screen once you have pressed SAVE this includes the Patients Name Date of Birth and Medicare Number To edit this information you should conta
81. tient rname EN New Patient Search Patient Current Password Report New Password Confirm New Password required 8 Logging In Once you have obtained your username and password via an email you will be able to log into the AuSCR Database 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 8 1 2 Click Registry Login towards the bottom of the right hand side of the page and the Login page will be displayed Figure 8 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 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 6 Click the Login button Important Note The system will timeout after 15 minutes of inactivity and you will be required to login again AuSCR Hospital User Version 9 10 11 2010 10 Figure 8 1 AUSCR Home Page AUSCE Australian Stroke Clinical Registry Home PATIENTS amp FAMILY MEMBERS Learn about how you can support the Australian Stroke Clinical Registry and how we pr
82. w up survey 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 access to Figure 22 2 If you encounter this error you will have to navigate through the right menu and navigate to another screen that you do have access to Contact AuSCR admin if you really need to revise your user access AuSCR Hospital User Version 9 10 11 2010 46 Figure 22 1 Optimistic Lock Exception AUSCE Australian Stroke Clinical Registry Home Error Another user changed the same data please try again org jooss 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 In partnershi
83. y 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 gt 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 L JEJE JEJE JEJE JE YE EE E retName JJ gp gp p gp gp p qr T JE JE JE E JE E JE E Y E E JE E T LastNamet J JD gr qr gp qp E JE X 4 4E CJ JC JE JC JC JC YE Y YE JE JE JC JC E 1E Address type Home 5 Business L Other Street Address L JEJE JE YE JE YE JE YE JE E JC YE E EE EYE JEJE E JE IEEE YE 1E YE 1 Suburb I JE JEJEJEYE EE JEJE JEJE JE YE TE E JE EE JEJE JC YE IE YE 1E YE Post Code JL ILE JEJE E stte DILDO Country OOU JEJE JE JEJE JEJE YE JE 3E JE YE EYE 1 Phone Number COOL mobie Number LE JE E JEJE EIL EL Medicare No LILILILILILILILILIL ospta mene SOOO pate of Birth CCU e Gender Male _ Female country of bith JL TL TL TE JEJE EE EE EE JEJE JE TEE TE ETE Language spoken JL JL TL JE JEJE JEJE JEJE JEJE JE JE JE E IE E IE E 1 interpreter needed ves No Is the patient of Aboriginal and or Torres Strait L Aboriginal but not Torres Strait Islander origin Islander origin L Torres Strait Islander but nat Aboriginal ori

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