Information to collect for patients during healthcare visits

Which demographic data should be collected and why

Patient demographics

1. Describe which, if any, specific demographic data should be collected and why. This information is found on the Registration Tab.

 Vital signs

2. Describe which, if any, specific vitals data should be collected and why. This information is found on the Vitals Tab.

 Medications

3. Describe which medication administration fields, if any, should be collected. This information is found on the Meds Tab and can be examined by clicking on any administered medication order.

Diagnoses & Problem lists

4. Describe which diagnosis or problem fields, if any, should be collected and why. Problems and diagnoses are listed together on the Problems Tab.

Visit dates and times

5. Describe which fields, if any, should be collected. This data can be found on the Encounters Tab in the Account section.

 Procedures

6. Describe which fields, if any, should be included for procedures. This data can be found on the Claims Tab in the Account section.

 Test results

7. Describe which fields, if any, should be included for test results. This data can be found on the Labs Tab.

 Clinical notes

8. Describe which fields, if any, should be included for clinical notes. This data can be found on the Notes Tab

Critical thinking

9. Which of the above data elements do you think is the most important data element to generate the Shoreline Birth Center’s rate of C-section? Why?

10. Describe how you will use this data element to calculate Shoreline’s rate of cesarean section delivery.

Review the resource, National birth statistics (found under 1: Overview & Resources along with this activity document) to answer the questions below.

 11. What was the national rate of cesarean delivery in the U.S. in 2016?

12. What was the national rate of cesarean delivery in the U.S. in 1996?

13. What was the national rate of cesarean delivery in the U.S. in 2009?

Critical thinking

14. Why should the calendar year 2016 be used to collect birth data to compare Shoreline’s rate of cesarean section delivery to the national rate? 

15. How many deliveries were reported at Shoreline Birth Center in 2016?

16. How many of these deliveries were vaginal?

17. How many of these deliveries were by cesarean section?

18. What was the rate of vaginal delivery?

19. What was the rate of delivery by cesarean section?

20. How did Shoreline’s rate of cesarean section delivery compare with the national rate of c-section delivery in 2016 percentage-wise?

21. Given the percentage you indicated in your answer to Question 20, calculate how many more women gave birth via cesarean section in 2016 at Shoreline than compared to the national rate?

22. Draft a statement to explain your findings to the Shoreline Birth Center administrative team.

Critical thinking

The medical director believes that the Birth Center has a high c-section rate because they are the area’s only high-risk birth center and, therefore, receive a higher percentage of high risk births. She believes that Shoreline’s high rate of c-section is related to the high-risk births and that c-section results in a safer birth experience for these families. Refer to the private patient data elements listed at the beginning of this activity and answer the following questions.

 23. How, in general, could this hypothesis be proven?

 24. What types of data elements could be used to prove this hypothesis? List the data you would include with your rationale for each element.

Read the resource Difference Between Descriptive and Inferential Statistics (found under 1: Overview & Resources along with this activity document). Answer the question below.

25. Based on the provided definition, does this data analysis involve descriptive or inferential statistics? Why?