STEMI-2017/C2/Initial-Patient-Details-data-entry/English

Topic: Data-entry of Initial Patient Details

Contributor Name: Jerry David, STEMI Team, Coimbatore

Reviewed by: Nancy Varkey, Spoken Tutorial Project, IIT Bombay

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

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.
Let both the script and narration say EMRI Ambulance	For EMRI Ambulance, 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: 9988776655 Address 1: X villa, X road, Coimbatore, Tamil Nadu
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 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 undergoes 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 at the bottom of the page	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  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 at the bottom of the page	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.
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 : 20/1/2015 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 : 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 : 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 : Stenting done	After this, we have to enter the PCI 1 Details : 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 at the bottom of the page	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 I’ll select Yes	Previous IHD: Check if Yes I’ll select Yes
Diabetes Mellitus: if ‘ Yes’ 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 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 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	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 : X villa, X road, Coimbatore, Tamil Nadu</u> The City:<u> Coimbatore the city Contact No: Mob : 9977885566 Occupation: Driver Aadhar Card No. 1100116 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	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.

Contributors and Content Editors

Nancyvarkey, PoojaMoolya