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

From Script | Spoken-Tutorial
Revision as of 11:30, 3 July 2020 by PoojaMoolya (Talk | contribs)

Jump to: navigation, search
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 –
  1. An Android tablet with STEMI App installed on it and
  2. 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
  1. Systolic BP Greater than 180 mmHg  - No
  2. Diastolic BP Greater than 110 mmHg - No
  3. Right Vs Left arm Systolic BP greater than 15 mmHg –No
  4. Significant closed head/facial trauma within the previous  3months - No
  5. Recent (within 6 weeks) major trauma, surgery (including laser eye surgery),GI/GU Bleed – No
  6. Bleeding or clotting problem or on blood thinners – No
  7. CPR greater than 10 min - No
  8. Serious systemic disease (e.g., advanced/terminal cancer, severe liver or kidney disease) –No
  9. History of structural central nervous system disease - No
  10. Pulmonary edema (rales greater than halfway up - No
  11. Systemic hypoperfusion (cool, clammy) – No
  12. 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.


  1. 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 -
  1. 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