View source for STEMI-2017/C2/Initial-Patient-Details-data-entry/English

<div style="margin-left:-0.035cm;margin-right:0cm;">'''Topic: Data-entry of Initial Patient Details'''

<div style="margin-left:-0.035cm;margin-right:0cm;">'''Contributor Name: Jerry David, STEMI Team, Coimbatore'''

<div style="margin-left:-0.035cm;margin-right:0cm;">'''Reviewed by: Nancy Varkey, Spoken Tutorial Project, IIT Bombay'''

'''Keywords: STEMI, STEMI App, Hospital Admission data entry on STEMI App'''


{| border=1
|- 
|  '''Visual Cue'''
|  '''Narration'''
|- 
|| Show title slide

'''Initial Patient Details'''
|| Hello and welcome to this tutorial on''' Data-entry of Initial Patient Details'''
|- 
|| Show learning Objectives Slide
|| In this tutorial, we will learn to –
* Enter initial patient details of a new patient on the''' STEMI App''' 
* in case of direct entry in a '''STEMI A, B, C and D Hospital'''.
* For '''EMRI''', the initial data entry will be different.
|- 
|| Show System Requirements Slide 
|| To practice this tutorial, you will need –
# An''' Android tablet with STEMI App''' installed on it and
# A working''' Internet''' connection

|- 
|| Pre-requisite slide
|| 
* You will also need to have working knowledge of the''' STEMI device''' and the''' STEMI App'''.
* If not, please refer to the''' STEMI''' tutorial series on this website.

|- 
|| '''Slide'''
|| The''' New Patient tab'''
* Contains basic details of the patient,''' Fibrinolytic checklist, Cardiac History, Co-morbid Conditions''' and''' Contact details'''.
* It marks the start of data entry of a new patient on admission to any '''Stemi Hospital.'''

|- 
|| 
|| After selecting the '''STEMI App''', we are in the '''STEMI Homepage.'''
|- 
|| Point to '''stemiCuser.'''
|| Scenario used in the demo for initial patient details, that is direct entry, is '''C Hospital.'''
|- 
|| Please '''Mention A/B''' in the blue box , there is only A

But the narration says A/B
|| But the data entry is identical for '''A, B '''and''' D Hospital '''scenarios.
|- 
|| Select''' New Patient''' tab.
|| Select''' New Patient''' tab.
|- 
|| 
|| Let’s assume a patient and enter the following data. 
|- 
|| Under''' Patient Details'''


'''BASIC DETAILS'''

* Patient Name: Ramesh

* Age: 53

* Gender: Male

* Phone Number: 9988776655

* Address 1: X villa, X  – road, Coimbatore – 000 000, Tamil Nadu
|| Under''' Patient Details,''' we have''' BASIC DETAILS'''.

We will enter the following details here-
* '''Patient Name''': Ramesh
* '''Age''': 53
* '''Gender''': Male
* '''Phone Number''' and
* '''Address'''

|- 
|| '''Payment: options'''

State BPL Insurance, Private Insurance, Self-Payment

Choose''' State BPL Insurance'''
|| Under''' Payment''': the options listed are -

'''State BPL Insurance, Private Insurance, Self-Payment'''

I’ll choose''' State BPL Insurance.'''
|- 
|| '''Date & time of Symptom onset'''

Date: 21/1/2016 Time: 9:00 am
|| Next comes''' Date & time of Symptom Onset.'''

Here we will enter the date and time when the symptoms were noticed.

I will enter the '''Date''' and''' '''the '''Time'''.
|- 
|| '''Admission >> '''select''' Direct'''
|| Next is''' Admission.'''

Here we will select the mode of hospital admission.

Since this is a case of direct admission to either of the '''A/B, C '''and''' D STEMI Hospitals''', I’ll select '''Direct'''.
|- 
|| When''' Direct''' is selected >> '''STEMI C Hospital Arrival Date/ Time'''
|| On selecting '''Admission Direct '''in a '''STEMI C Hospital''', we will prompted to enter '''STEMI C Hospital Arrival Date '''and '''Time.'''
|- 
|| Text on screen “D Hospital”
|| Likewise, in case of '''STEMI D Hospital,''' we will be prompted to enter '''STEMI D Hospital Arrival Date '''and''' Time'''
|- 
|| Text on screen “A/B Hospital”
|| In the case of '''STEMI A/B Hospital, '''we will be prompted to enter '''STEMI A/B Hospital Arrival Date/and Time. '''
|- 
|| Manual ECG taken:Select''' Yes'''

Drop down''' ECG date/ time'''

'''Date''': 21/1/2016 '''Time''': 9:20 am
|| '''Manual ECG taken''': 

If '''Yes''' , then we have the drop- down''' ECG Date '''and '''Time.'''
|- 
|| '''STEMI Details'''

* STEMI Confirmed''' Yes'''

* '''STEMI Confirmed Date/ Time'''

'''Date''': 21/1/2016 '''Time''': 9:25am
|| Next comes '''STEMI Confirmed'''.

If '''Yes,''' we will be prompted to fill the '''Date''' and '''Time.'''
|- 
|| '''Transport Details'''

* Mode of Transport to Hospital

Options –Public, GVK Ambulance, Private Ambulance,Private
|| Lastly, we have to enter the''' Transport Details.'''

Here we choose the mode of transport by which the patient arrived at the '''C Hospital.'''
|- 
|| Screen on text
|| Under''' Mode of Transport to Hospital,''' the options are–

'''Public Vehicle, GVK Ambulance, Private Ambulance, Private Vehicle'''
|- 
|| Narration only
|| The '''GVK EMRI '''option would be possible in case of '''Direct Admission '''in a '''STEMI D '''and '''A/B Hospital.'''
|- 
|| '''Ambulance Call Date & Time'''

'''Ambulance Arrival Date & Time'''

'''Ambulance Departure Date & Time'''

|| If we choose''' Private Ambulance''', we get the drop -downs

*'''Ambulance Call Date & Time'''

*'''Ambulance Arrival Date & Time'''

*'''Ambulance Departure Date & Time'''
|- 
|| Text on screen

Text on screen
|| We cannot select''' GVK EMRI Ambulance.''' 


Under''' STEMI protocols''' the''' EMRI ambulances''' always shift the patient to a''' D''' or''' A/B''' Hospital. 
|- 
|| Text on screen
|| These are the hospitals where the patient could undergo''' thrombolysis''' or''' PCI treatment.'''
|- 
|| Message at the bottom ‘'''You cannot select GVK Ambulance’'''
|| Hence we get a message at the bottom ‘'''You cannot select GVK Ambulance’'''
|- 
|| Choose''' PRIVATE'''
|| I’ll choose''' PRIVATE VEHICLE.'''
|- 
|| Select the''' Save & Continue button''' 
|| Select the''' Save & Continue''' button at the bottom of the page.
|- 
|| Please wait if buffering sign is seen
|| Please wait if buffering sign is seen.
|- 
|| '''Saved Successfully”''' message appears
|| Immediately the page gets saved and “'''Saved Successfully”''' message appears at the bottom.
|- 
|| '''Fibrinolytic Checklist'''.
|| The''' App''' now takes us to the next page, that is,''' Fibrinolytic Checklist'''.
|- 
|| Check the following
# '''Systolic BP Greater than 180 mmHg''' No
# '''Diastolic BP Greater than 110 mmHg''' No
# '''Right Vs Left arm Systolic BP greater than 15 mmHg''' No
# '''Significant closed head/facial trauma within the previous &nbsp;3months''' - No
# '''Recent (within 6 weeks) major trauma, surgery (including laser eye surgery),GI/GU Bleed''' No
# '''Bleeding or clotting problem or on blood thinners''' No
# '''CPR greater than 10 min''' No
# '''Serious systemic disease (e.g., advanced/terminal cancer, severe liver or kidney disease)''' No
# '''History of structural central nervous system disease''' No
# '''Pulmonary edema (rales greater than halfway up''' No
# '''Systemic hypoperfusion (cool, clammy)''' No
# '''Does the patient have severe heart failure or cardiogenic shock such that PCI is preferable such that PCI is preferable? No
|| As we are entering the details of a Male patient, we only have 12 points to check.






There will be 13 items displayed If the patient was female. 



The extra item is '''Pregnant Female Ye/No''', which we have to fill according to the gender of the patient.






I’ll check all the 12 points as ‘'''No'''’ for this demo.

|- 
|| Select the''' Save & Continue''' button
|| Select the''' Save & Continue''' button at the bottom of the page.
|- 
|| 
|| Please wait if buffering sign is seen.
|- 
|| “'''Saved Successfully”''' message appears
|| Immediately the page gets saved and “'''Saved Successfully”''' message appears at the bottom.

|- 
|| '''CARDIAC HISTORY'''
|| The''' App''' now takes us to the next page, that is, ''' CARDIAC HISTORY.'''
|- 
|| Previous MI: History Check Yes

MI 1 – options:

Anterior wall, Inferior Wall, Posterior Wall, Lateral Wall, RV Infarction

Choose''' Anterior Wall'''

MI1 date : 2/1/2015

MI1 details: ________________
|| '''Previous MI:''' If''' Yes,''' we then have drop-downs '''MI 1 & MI 2'''

Under''' MI1, '''we have the options –

'''Anterior wall, Inferior wall, Posterior wall, Lateral wall, RV Infarction.'''

I’ll choose''' Anterior Wall.'''

Once we select''' MI 1,''' we further get drop-downs''' MI1 Date & MI 1 Details'''

I’ll enter the''' Date :'''

In''' MI1 Details,''' I will type''' “Patient was stable at the time of discharge”'''.
|- 
|| Similarly for MI 2
|| Similarly, enter the data for''' MI 2'''
|- 
|| '''Angina''' Select ‘'''Yes'''’


In the Duration: drop-down, select '''2 years'''
|| Next comes''' Angina'''.

If''' ‘Yes’''' we then get a dropdown''' Duration:'''

Here I will select''' 2 years.'''

We have to enter the details based on the patient's past history.
|- 
|| 
'''CABG''' Select''' ‘Yes’'''

'''CABG Date&nbsp;: 7/1/2015'''
|| Next is''' CABG'''.

If''' Yes,''' enter the''' CABG Date:'''

You have to enter the date depending on whether the patient underwent '''CABG''' in the past.
|- 
|| '''PCI 1 '''if '''Yes'''

'''PCI 1 Date'''&nbsp;: 7/1/2015
|| Then comes''' PCI 1'''.

If''' Yes, '''we get a dropdown''' PCI 1 Date''' and''' PCI 1 Details.'''

Once again, you have to enter the date depending on whether the patient had a '''PCI''' done in the past.
|- 
|| '''PCI 1 Details&nbsp;:''' Stenting done
|| After this, we have to enter the''' PCI 1 Details&nbsp;:'''


I will enter''' “Stenting done”.'''
|- 
|| Similarly for PCI 2
|| Similarly, enter the data for''' PCI 2.'''
|- 
|| '''Diagnosis'''
* Chest Discomfort : options – Pain, Pressure, Aches

Choose''' Pain'''





* Location of Pain: options – Retrosternal, Jaw, L arm, R arm. Back

Choose''' Retrosternal'''



* Pain Severity Pain scale 1 – 10

Choose''' 8'''






* '''Palpitation''' Check










* '''Pallor'''
* '''Diaphoresis'''
* '''Shortness of Breath''' Check



* '''Nausea/ Vomiting''' Check


* '''Dizziness:''' Check


* '''Syncope:'''
|| Next comes''' Diagnosis.'''

Under '''Diagnosis''' we have the following
* '''Chest Discomfort:'''

The options are–''' Pain, Pressure, Aches'''

I’ll choose''' Pain'''

* '''Location of Pain:'''

The options are–''' Retrosternal, Jaw, Left arm, Right arm, Back'''

I’ll choose''' Retrosternal'''

* Next we have to enter the''' Pain Severity:'''

On a scale from 1 to 10; 1 being least painful and 10 being extreme pain.

I’ll choose''' 8'''

* '''Palpitations''' : 

Check this option as '''Yes''', if there are palpitations.

Similarly for the rest, check if''' Yes.'''

I’ll check a few as''' Yes.'''
* '''Pallor: Yes'''
* '''Diaphoresis:'''
* '''Shortness of Breath''':

Check this, if its so.
* '''Nausea/ Vomiting: Yes'''

Again check, if the same is observed.
* '''Dizziness:''' Yes

check Yes if it is so.
* '''Syncope:Yes'''

|- 
|| '''Clinical Examination'''


* '''Height (cm)''' 175
* '''Weight (kg)''' 80
* '''BMI''' auto populated



* '''BP Systolic''' 140
* '''BP Diastolic''' 110
* '''Heart Rate''' 82


|| Under''' Clinical Examination,''' we will enter the following-
* '''Height (in cm)''' 175
* '''Weight (in kg)''' 80
* '''BMI''' gets auto populated once height and weight are entered.

* '''BP Systolic''' 150 mm Hg
* '''BP Diastolic''' 110 mm Hg
* '''Heart Rate''' 82 beats per minute

|- 
|| Select the''' Save & Continue''' button.
|| Select the''' Save & Continue''' button at the bottom of the page.
|- 
|| 
|| Please wait if buffering sign is seen.
|- 
|| “'''Saved Successfully”''' message appears
|| When the page gets saved, the success message appears at the bottom.

|- 
|| The App now takes us to the next page '''CO–MORBID CONDITIONS'''
|| The''' App''' now takes us to the next page, that is,''' CO–MORBID CONDITIONS.'''
|- 
|| Under Co- Morbid Conditions

* '''Smoking'''

Options''' Non Smoker''',''' Current Smoker, Past Smoker , Unkown or Passive'''

'''Current Smoker '''is selected 

Drop-down options

'''Beedies''' Check if smokes
'''Cigarettes''' Check if smokes

'''Number''' 1 pack a day

'''Duration''' 20 yrs
|| Under''' Co-Morbid Conditions,''' we will be prompted to enter the following details.* '''Smoking'''

Ask the patient or relatives about the patient’s smoking habits.

We have options-''' Non Smoker, Current Smoker, Past Smoker, Unknown and Passive'''

If we select''' Current Smoker, Past Smoker or Passive,''' then we get further drop- downs.


I’ll select''' Current Smoker'''

# '''Beedies'''
#:Check if the patient smokes this.
# '''Cigarettes'''
#:Check if the patient smokes this.
#:
#:I’ll check both as''' ’Yes’'''
#:
# In''' Number,''' enter the no. of beedies or cigarettes the patient smokes daily.
#:I will enter''' 12.'''
#:
#'''Duration''' is where we will enter the no. of years the patient has been smoking/ or has smoked previously.
#:I will enter''' “15 yrs”'''
|- 
||'''Previous IHD:''' Select Yes / No

Select''' Yes'''

||'''Previous IHD:'''

Check if''' Yes'''

I’ll select''' Yes'''
|- 
|| '''Diabetes Mellitus:''' if ‘''' Yes’'''

Point to drop-down

'''Duration:''' 10 yrs

'''OHA:''' Glycophage '''Insulin:''' Human Actrapid
|| '''Diabetes Mellitus:''' if''' ‘Yes’'''

We have drop-downs''' Duration, OHA & Insulin'''


For '''Duration:''' I will enter 10 yrs.

'''OHA:''' For eg-'''Glycophage'''

'''Insulin:'''For eg- '''Human Actrapid'''
|- 
|| '''Hypertension:''' select''' Yes'''

Point to drop-down

 '''Duration:''' 15 yrs

|| '''Hypertension:''' if''' ‘Yes’'''

We have drop-downs''' Duration, Medications '''and''' Medications details.'''

'''Duration: '''I will select''' 15 yrs'''
|- 
|| 
* '''Medication''' check if patient is on medications
* '''Medication details: Tenormin,Amilodipine- H'''

|| '''Medication:''' Check this, if the patient is on medications.

Then under''' Medication details:''' we will enter the names of some '''Hypertension''' drugs. 

''For eg-''' Tenormin, Amilodipine H, etc,.'''''
|- 
|| Dyslipidemia – dropdown if yes
* '''Medication:''' Check if''' Yes'''
* '''Medication Details;''' Atorvastatin
|| '''Dyslipidemia:''' Again, if '''Yes''', we get drop-downs.

''' Medication & Medication Details'''

'''Medication:''' Check if''' Yes'''

'''Medication Details: '''For eg- Atorvastatin
|- 
|| Peripheral Vascular Disease: Check if Yes
|| '''Peripheral Vascular Disease''' Check if''' Yes'''
|- 
|| Stroke Check if Yes
|| '''Stroke''' Check if '''Yes'''
|- 
|| Bronchial Asthma: check if Yes
|| '''Bronchial Asthma:''' Check if '''Yes'''
|- 
|| Allergies if yes

Dropdown Allergy Details: dairy products
|| '''Allergies''' If '''Yes''',

We get the drop-down''' Allergy details''':

Here I will enter''' Dairy products.'''
|- 
|| Select the''' Save & Continue'''
|| Select the''' Save & Continue''' button at the bottom of the page.
|- 
|| 
|| Please wait if buffering sign is seen.
|- 
|| '''Saved Successfully''' message appears.
|| The page gets saved and “'''Saved Successfully”''' message appears at the bottom.
|- 
|| '''CONTACT DETAILS'''
|| The''' App''' now takes us to the next page with the title -''' CONTACT DETAILS.'''
|- 
|| Under''' Contact Details'''

'''Relation Name :''' Ramu

'''Relation Type:''' Father

'''Address :''' X villa, X road, Coimbatore, Tamil Nadu

'''City:''' Coimbatore

'''Contact No: Mob :''' 9977885566

'''Occupation:''' Driver

'''Aadhar Card No. '''XYZ001100 

'''ID Proof:''' I’ll Choose Driving License

Upload Aadhar: snapshot of the Aadhar card in the device >> select browse tab >> access the image file >> save it on to the App

|| Under''' Contact Details,''' we have to enter the details of the patient’s relative.

'''Relation Name :''' Ramu

'''Relation Type:''' We have the options''' Father, Spouse, Others'''

I’ll choose''' Father'''

Then enter the''' Address :'''

The '''City:''' 

'''Contact No: Mobile :'''

'''Occupation:''' 

'''Aadhar Card No. '''

'''ID Proof:''' 

We have options''' Voter ID, Driving License, Family Card, Passport, Pan Card, Others'''

I’ll choose''' Driving License.'''


'''Upload Aadhar:''' Take a snapshot of the''' Aadhar card''' on the '''device''', then select the '''Browse''' tab.

And access the image file from the gallery and save it on to the''' App'''.

Do likewise for''' Driving License.'''


This information will help us during the follow up period to get back to the patient's relative.
|- 
|| Select''' Save & Continue''' Tab
|| Select the''' Save & Continue''' button at the bottom of the page.
|- 
|| 
|| Please wait if buffering sign is seen.
|- 
|| '''Saved Successfully''' message appears.
|| Immediately the page gets saved and ‘'''Saved Successfully’''' message appears at the bottom.
|- 
|| 
|| This completes the''' Hospital Admission data entry''' in case of direct entry in a''' STEMI A/B, C & D Hospital.'''
|- 
|| 
|| Let us summarize.
|- 
|| Show Summary Slide
|| In this tutorial, we have learnt to -
* Complete the data entry of a new patient on the''' STEMI App''' 
*at the time of admission to any '''STEMI Hospital.'''

|- 
|| Show STEMI INDIA slide
|| '''STEMI INDIA'''
* was set up as a ‘not for profit’ organisation
* primarily to reduce delays in accessing appropriate care for heart attack patients
* thereby saving the lives of X% of the patients
* and reducing deaths due to heart attacks

|- 
|| Show Spoken Tutorial Project Slide
|| Spoken Tutorial Project, IIT Bombay is funded by NMEICT, MHRD, Govt. of India.


For more details, please visit http://spoken-tutorial.org
|- 
|| Show THANK YOU slide
|| This tutorial has been brought to you by '''STEMI INDIA''' and '''Spoken Tutorial Project, IIT Bombay.'''

This is Nancy Varkey IIT Bombay, signing off.


Thanks for watching.
|-
|}