cihi nacrs abstracting manual

What are data submission reports? 14b. What are data quality reports? 14c. What are management reports? 14d. What are eNACRS Reports? 15. What are the costs for reports? 16. Are there different ways to define peer groups in eNACRS Reports. Data Elements 17. Why is the Coder Number a mandatory data element? 18. Can I submit information that is not included in the NACRS data element list. Pick-Lists 19. What is a pick-list? 20. What information is captured with pick-lists? 21. Are Presenting Complaint and ED Discharge Diagnosis pick-lists mandatory reporting for Level 2? Implementation 22. How long does it take to start data submission? Vendors 23. Who are licensed NACRS vendors? 24. Rather than use an external vendor, can a facility use its own in-house system to submit CIHI data? 25. What is the cost of software from a licensed NACRS vendor. Client Support 26. What kind of support does CIHI provide to facilities using NACRS? 27. How can I submit questions regarding NACRS? 28. How can I request new services? 29. Where are the NACRS manuals and how can I access them. Page 2 FAQ General Information and Background 1. What is NACRS? NACRS is the National Ambulatory Care Reporting System at the Canadian Institute for Health Information (CIHI). Emergency and ambulatory care is one of the largest-volume patient activities in Canada. Recognizing the need for data about this sector, CIHI developed the NACRS database. NACRS provides hospitals and community-based organizations with a standard data collection and reporting tool to capture data for ambulatory care visits, including day surgery, ambulatory care clinics and emergency departments (EDs). Data is available from 2001 onwards. 2. Is submission to NACRS mandatory. CIHI does not mandate data submission to NACRS. Data Submission 3. What are the different data submission options. The three data submission options are referred to as Level 1, Level 2 and Level 3.

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Until you sign in, we do not know which price applies to you. CIHI often publishes reports in both English and French, though there is sometimes a delay between the publication of the English version and the availablility of the French version. The series information will always be available in both English and French, even if the report itself is only available in one language. If your browser does not support PDFs and you do not have a PDF viewer, you can download Adobe Acrobat Reader free of charge at Adobe.com. If the publication is not available in a downloadable media type or the price is not free, you will have to add it to your cart so that you can order it. You must be signed in before adding an item to your cart, so if you have not already done so, you will be redirected to the sign in screen. This will give you more detailed information about that particular publication. To sign in, enter your username and password in the top-right corner of your screen. They also provide instructions for collecting inpatient and ambulatory care abstracts through the DAD and NACRS databases. They contain definitions, valid code values and collection guidelines for each data element. Please refer to for the current application and checklists. NACRS facilitates comparisons and benchmarking across jurisdictions provincially and nationally through the use of standardized definitions and coding standards that adhere to national and international standards. NACRS Level 2 will provide patient level, demographic and wait time information and clinical data including presenting complaint and discharge diagnosis. Note: This will be the same as the PHN for BC residents. The period submitted follows the submission period dates defined by the reporting jurisdiction, so BC s 13 fiscal periods do not apply to out of province records. Note: Only the first three digits of the postal code (i.e., FSA) will be provided. What reports are available from NACRS? 14a.

ED abstracts are not resubmitted at Level 3. Level 3 ED abstracts once coding and abstracting is completed. Day surgery and other ambulatory care records are not submitted to NACRS. ED, day surgery and other ambulatory care records at Level 3. Page 4 FAQ 8. What is the difference between data submission level and reporting level. Data submission level refers to the data submission options: Level 1, Level 2 and Level 3. Reporting level refers to the data submission levels with which the facility will submit data to NACRS. Reporting Level Codes are set out in the table below. Facilities must choose the correct Reporting Level Code when submitting their Facility Information File (FIF). However, if a facility has submitted the FIF only, and no data has been submitted, the Reporting Level Code can be changed, by updating the FIF. 10. If a facility is submitting data at Level 1 or Level 2 and would also like to begin submitting data at Level 3 within the same fiscal year, when can Level 3 data submission begin. Facilities can start Level 3 data submission in any selected month, as long as The Reporting Level Code on the FIF is D (Level 1 and Level 3) or E (Level 2 and Level 3); and Facility testing for each applicable data submission level has been completed. For example, if a facility with reporting level D begins data submission at Level 1 in July and wishes to submit at Level 3 in October for the same fiscal year, this can be accommodated if facility testing at Level 3 has been completed. Please note that once Level 3 ED data has been accepted for a submission period, Level 1 or Level 2 data cannot be accepted for that period. Page 5 FAQ 11. Are data submission processes different for the three data submission options? No. Data submission processes for levels 1, 2 and 3 are basically the same. All data, regardless of data submission level, is submitted to NACRS via CIHI’s electronic Data Submission Services (eDSS).

Level 3 data submission is available for all types of records (that is, emergency, day surgery and other ambulatory care visits). Level 1 and Level 2 are available for emergency visits only. The following table summarizes the information collected for each of the different data submission options. The main reason for offering different data submission options is to reduce the burden of data collection for facilities. Level 3 data submission requires that all mandatory data elements be collected before an emergency record can be accepted at CIHI. By removing the requirement to code the diagnoses and interventions and by reducing the number of mandatory data elements in Level 1 and Level 2 data submission, facilities are able to submit data that is more readily available in their hospital information systems, such as admission discharge transfer (ADT) systems or emergency department information systems (EDIS), and receive timely wait time information. 5. What are the differences between data submission at Level 1, Level 2 and Level 3? The main difference between the levels of data submission is the amount of data that needs to be submitted. The table under question 3 highlights the differences. It is also important to note that the different data submission options apply to ED visits only. Level 3 is the only option available for day surgery and other ambulatory care records. Please refer to the Data Element Summary on the NACRS website for a detailed list of all current data elements and their submission level applicability. 6. Which data submission options are available. Facilities submitting ED information can choose to submit data at Level 1, Level 2 or Level 3. Currently, data for day surgery and other ambulatory care services must be submitted at Level 3. 7. Can I submit data with more than one data submission option. Multi-level Facilities can choose to submit ED data at Level 1 or Level 2 as well as: Day surgery and other ambulatory care records at Level 3.

What are management reports. Management reports are a series of reports which enable clients to better monitor timeliness, completeness and quality of data submissions throughout the open fiscal year. These reports are cumulative (updated after each successful data submission) and are available based on the respective submitting facility or as a provincial summary. Page 7 FAQ Management Reports Report Name Description Records Submitted by Submission Status This report provides a summary of the total records submitted by submission status, submission level, reporting period and population. Information in this report is presented for each period within the fiscal year. Errors Encountered on Submission The facility report lists the top five errors encountered by each facility for each reporting period. What are eNACRS Reports.There are three categories of reports: Dashboards provide snapshots of key indicators and messages to get you started; Quick Reports present accessible and user-friendly trending and comparison features; and Custom Reports provide options for customizing the Quick Reports, including the ability to define your own custom peer groups.They are facility-specific and allow comparative results with other hospitals. These cumulative reports are available by the 15th business day of the month. Report topics include ED wait time indicators, utilization and case mix. 15. What are the costs for reports. There are no additional costs for reports. 16. Are there different ways to define peer groups in eNACRS Reports. Yes, eNACRS Reports allow complete freedom to create user-defined peer groups or clients can choose to run reports based on CIHI peer grouping methodology. Why is the Coder Number a mandatory data element. The alphanumeric Coder Number identifies the person responsible for completing the abstract and is assigned by the facility.

Currently this includes Ontario, Nova Scotia, the Yukon, British Columbia, Alberta, Manitoba and Saskatchewan. Prince Edward Island receives an annual cut of the NACRS data. 13. What is the difference between hard edits and data quality warnings (soft edits). Hard edits identify NACRS data elements that are not properly formatted or that contain invalid values. Unlike the Discharge Abstract Database (DAD), which accepts records with a hard error, when a NACRS record does not pass a hard edit, the entire record is rejected and is not populated into the database. Rejected records must be corrected and resubmitted to be accepted into the NACRS database. Data quality warnings (or soft edits) identify potential errors. Page 6 FAQ Reports 14. What reports are available from NACRS.Data submission reports are operational reports used by individuals who are responsible for submitting facility data to CIHI. They consist of summary reports on processed data as well as reports on erroneous records. They include the following: Data Submission Reports Report Name Description Submission Status Report Status summary of processed data. It confirms that no records were rejected or provides the total number of records received, records accepted and records rejected. Outstanding Rejected Records Report (ORRR) Reports on records that were rejected but not yet resubmitted and accepted into the NACRS database. 14b. What are data quality reports. Data quality reports are cumulative reports that may identify data quality issues. These reports are hospital- and period-specific and indicate occurrences of unknown values submitted for data elements used in the calculation of ED wait time indicators. There is a summary report and a record-level report available for each facility. Refer to the CIHI NACRS Data Quality Reports Manual for additional information about these reports. This manual is available through the “NACRS Applications” on the secure Applications section of CIHI’s website. 14c.

The online eQuery tool allows clients to search an online knowledge base of previously asked questions related to any aspect of NACRS abstracting; if clients do not find the answer to their question, they may submit a new question to the NACRS client services representative (CSR) via the same online tool, and the CSR will respond within 48 hours. Questions regarding content of the NACRS manual or NACRS reports and coding queries can all be submitted via the eQuery tool. Clients can access eQuery on the Applications page of CIHI’s website. How can I request new services. The request for new services must be submitted by one of the contacts listed on your facility’s FIF. Page 11 FAQ 29. Where are the NACRS manuals and how can I access them. Each fiscal year, NACRS produces updated versions of the NACRS Manual in English and French. If you do not have access to this Application, a request can be submitted to the Centralized Client Services team (refer to question 28 for instructions on how to submit request for new services). Other interested parties may purchase manuals through CIHI’s eStore webpage.We are a non-profit group that run this service to share documents. We need your help to maintenance and improve this website. To that end, the linked dataset will be used to develop and validate health care indicators and performance measures as well as perform survival and outcome analyses on acute inpatient data while considering such elements as efficiency, continuum of care, outcomes and disparities in health and longevity. In addition to the deaths occurring in hospitals which are captured in the CIHI datasets, the linked file will provide information on patients who have died following their discharge from an acute care hospital or an emergency room. Statistics Canada does not have Quebec hospitalization data (RAMQ) as part of its data holdings and thus hospitalizations that occurred in the province of Quebec are not included in the linked datasets.

Over time, the DAD has also been used to capture data on day surgery, long-term care, rehabilitation and other types of care.Collection of each data element may be mandatory, mandatory if applicable, optional or not applicable. Collection requirements can vary by jurisdiction and by data year. Researchers will find the listings of DAD data elements under the heading “Data Elements” at the DAD Metadata website. The documents on the website include information on mandatory versus optional collection status for each data element by jurisdiction, which is key to understanding coverage of data elements in the DAD. Please note that DAD data elements that could present an increased risk of direct or indirect identification of an individual were excluded in the DAD analytical file for this record linkage project. Client visit data is collected at time of service in participating facilities from several jurisdictions.Similar to DAD, collection of each data element may be mandatory, mandatory if applicable, optional or not applicable. Collection requirements can vary by jurisdiction and by data year. Researchers will find the listings of NACRS data elements under the “Data Elements” section of the NACRS Metadata website. The documents on the website include information on mandatory versus optional collection status for each data element by jurisdiction, which is key to understanding coverage of data elements in NACRS. OMHRS includes information about mental and physical health, social supports and service use, as well as care planning, outcome measurement, quality improvement and case-mix funding applications.Collection of each data element may be mandatory, optional, optional depending on an associated data element, or not applicable. Researchers will find the listings of OMHRS data elements under the heading “Data Elements” at the OMHRS Metadata website.

In the event that abstract corrections are required, the Coder Number allows the facility to assign those records to the appropriate person. Although this data element is mandatory, a default value can be used should the facility not require this information. 18. Can I submit information that is not included in the NACRS data element list? Yes. All data submission levels include the special project information fields (data elements 79 to 96), which provide the option to abstract additional information about the patient’s emergency or ambulatory care visit. Pick-Lists 19. What is a pick-list. Developed to reduce the burden of data collection, a pick-list is a list from which predefined words or phrases can be selected. Pick-lists allow structured data input. If the pick-list is standardized across all data entry sites, it can reduce variation in data collection, thereby improving data quality. 20. What information is captured with the NACRS pick-lists. Two pick-lists are available for use with ED visits submitted at any submission reporting level: the Presenting Complaint pick-list and the ED Discharge Diagnosis pick-list. The Presenting Complaint List (PCL) consists of approximately 165 common initial complaints received from patients entering the ED and was developed by the Canadian Emergency Department Information System (CEDIS) Working Group. Complaints on the PCL are not mapped to ICD-10-CA codes. The ED Discharge Diagnosis pick-list is composed of the Canadian Emergency Department Diagnoses Shortlist (CED-DxS), which was developed as a collaborative effort between CIHI and the Canadian Emergency Department Information Systems (CEDIS) Working Group. It consists of a subset of more than 800 diagnoses derived from a complete list of more than 17,000. All diagnoses are provided in common terms and are mapped to ICD-10-CA codes. Interventions are not included in the CED-DxS. Copies of the NACRS pick-lists are available on CIHI’s eStore website. Page 9 FAQ 21.

Are Presenting Complaint and ED Discharge Diagnosis pick-lists mandatory reporting for Level 2? Either the Presenting Complaint (data element 136) or ED Discharge Diagnosis (data element 137) must be completed for Level 2 data submission. Presenting Complaint and ED Discharge Diagnosis are optional data elements for Level 1 and Level 3. Implementation 22. How long does it take to start data submission. From the time decisions about data scope and volume are made, facilities should allow a minimum of 6 and up to 18 months to prepare for data submission to NACRS. The preparation time required for a facility to implement NACRS data submission will vary based on the facility’s requirements (software, hardware, staffing, etc). Data submission does not have to begin at the start of the fiscal year; facilities can begin submitting data at any time during the year. Vendors 23. Who are licensed NACRS vendors. Software cost is vendor-specific. Please contact vendors directly for pricing information. Page 10 FAQ Client Support 26. What kind of support does CIHI provide to facilities using NACRS. A dedicated NACRS team supports facilities by: Providing support and guidance for the implementation of NACRS data submission, including customized information sessions; Working in consultation with stakeholders to provide the data and reports that clients require and the necessary tools to best collect emergency and ambulatory care information; Offering one-on-one support to assist clients with any problems or questions and ensure that users are able to utilize the database to their best possible advantage; Monitoring the database to identify and resolve any data quality issues; and Developing and offering ongoing education courses, including eLearning sessions and faceto-face workshops. 27. How can I submit questions regarding NACRS.

The documents on the website include information on mandatory versus optional collection status for each data element by type of assessment, which is key to understanding coverage of data elements in OMHRS. Deaths are reported by the provincial and territorial Vital Statistics Registries to Statistics Canada; the information provided includes demographic and cause of death information. Cause-of-death information is coded using the version of the International Classification of Diseases (ICD) in effect at the time of death. Records eligible for record linkage were deaths that occurred from January 1, 2000 through December 31, 2012. The cohort files (DAD, NACRS, and OMHRS) include all the records from the cohort (linked and unlinked). Names and other personal identifiers are not included on the file. In order to use a file as a person-based file, the researcher must transform the data to include all hospital information for one person as one record (one row on the data file). As a fully accredited, progressive health care organization, Geraldton District Hospital is committed to providingDuties Include: Applies appropriate codes and abstracts all inpatient records (DAD) and emergency departmentIf you interested in combining a fulfilling lifestyle with a challenging opportunity, please submit your. By selecting Follow, you agree to get updated information and new jobs for this company by email. To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to upgrade your browser.

Related Papers INJURY SURVEILLANCE PILOT PROJECT By Hassan Soubhi The burden of illness of osteoporosis in Canadian men By Jonathan Adachi The utility of administrative data for neurotrauma surveillance and prevention in Ontario, Canada By Daria Parsons Data collection on patients in emergency departments in Canada By Brian Rowe Epidemiological Trends of Traumatic Brain Injury Identified in the Emergency Department in a Publicly-Insured Population By Michael Cusimano READ PAPER Download pdf. It looks like your browser needs updating. For the best experience on Quizlet, please update your browser. Learn More. True False False Diagnosis types are applied to codes on a National Ambulatory Care Reporting System (NACRS) abstract. A provincial-specific manual is also with jurisdictional-specific rules and guidelines. True False False The discharge abstract database (DAD) is a database that contains acute care inpatient visits. True False True Entering an external cause code into the WinRecs abstract automatically populates the diagnosis type field with diagnosis type (9). True False True Entering the postal code into the WinRecs abstract automatically populates the residence code. True False True Entering an ICD-10-CA diagnosis code into the WinRecs abstract automatically populates the diagnosis type field with the correct diagnosis type. True False False The F4 (function) key saves the WinRecs abstract. True False False Project 100 is mandatory for those completing abstracts in the province of Ontario only. True False True Cellulitis is a diffuse spreading infection of the skin, usually caused by gram-positive cocci. Staphylococcus aureus is the most common infecting organism. True False True Cellulitis with an abscess, is classified to the code(s) for a. Abscess, by site, only b. Abscess, by site and cellulitis, by site c. Cellulitis, by site, only d. Infection of skin and subcutaneous tissue, by site a. Abscess, by site, only Gangrenous cellulitis is classified to a.

L03.8 Cellulitis by other sites b. L08.8 Other specified local infections of skin and subcutaneous tissue c. R02 Gangrene, not elsewhere classified c. R02 Gangrene, not elsewhere classified Dermatitis and eczema are terms used synonymously and interchangeably. True False True A patient with diabetes mellitus is admitted to hospital for treatment of chronic asthma. During the admission, the patient is seen by an endocrinologist and he is started on insulin. He is diagnosed with a post-operative wound infection on post-operative day 2. He is started on intravenous (IV) antibiotics and his stay is extended by 3 days. While in hospital, the patient's COPD exacerbates. He is seen in consultation by a respirologist who orders inhalation therapy, antibiotics and steroids. The patient is diagnosed with viral gastroenteritis. The dehydration is treated with intravenous (IV) fluids. A tonsillectomy and adenoidectomy is performed. True False False A cataract in a patient with diabetes mellitus is always classified to H28.0 Diabetic cataract. True False False Focal laser to precisely seal off leaky vessels in the macular region of the retina, to prevent further deterioration of the retina, is classified to generic intervention: a. 13 - Control of bleeding b. 59 - Destruction c. 80 - Repair b. 59 - Destruction Aging is the most common cause of cataracts. True False True Patients with type 2 diabetes mellitus are likely to develop senile cataracts. True False True After-cataract is usually treated with YAG laser capsulotomy. True False True It is mandatory to assign an additional code to identify the underlying cause of secondary glaucoma. True False True The paranasal sinuses include the maxillary, frontal, sphenoidal and ethmoidal sinuses. True False True Chronically diseased tonsils and adenoids are classified according to whether the tissue is chronically inflamed or hypertrophied or enlarged.

True False True Mastoidectomy surgery described as canal wall up involves removal of the bony wall that separates the middle ear from the mastoid. True False False Patients with chronic otitis media often require a tympanoplasty. The most responsible diagnosis is always the code for otitis media. True False True F7 is the function key used to save an abstract in WinRecs. True False True In WinRecs, the residence code automatically populates when the postal code is entered. True False True In WinRecs, diagnosis type (9) is automatically applied when an external cause code is entered. True False True The ICD-10-CA alphabetical index is divided by chapter, category, subcategory, code. True False False CCI is divided by chapter, group, generic intervention (or rubric), code. True False False Diagnosis typing applies to diagnosis codes submitted to the Discharge Abstract Database (DAD). True False True A diagnosis type must be applied to each ICD-10-CA code entered on a DAD abstract. True False True Diagnosis type (9) is applied to an external cause code. True False True Significant diagnoses include the most responsible diagnosis and secondary diagnoses. True False False Secondary-type (3) diagnoses may be assigned to identify supplemental information or information required for research purposes. True False True Diagnosis type (3) is applied to newborn diagnosis codes that do not meet the criteria for significance. True False False The purpose of project 100 is to provide the Ontario Ministry of Health and Long Term Care an indication of the volume of abstracts that were completed based on incomplete documentation. True False True The Discharge Abstract Database (DAD) Abstracting Manual includes definitions and data collection instructions for all data elements on an emergency department abstract. True False False An abstract is submitted to the DAD by all Canadian jurisdictions for all acute care inpatient visits.

True False False classification A systematic way to arrange elements into groups or categories, so that data can be easily tabulated, aggregated and stored for statistical analysis. SimplyHired may be compensated by these employers, helping keep SimplyHired free for jobseekers. SimplyHired ranks Job Ads based on a combination of employer bids and relevance, such as your search terms and other activity on SimplyHired. For more information, see the SimplyHired Privacy Policy. Financial Analyst North Bay Regional Health Centre - North Bay, ON. Experience using multiple data sources (financial, statistical, case costing, CIHI databases, Ministry data etc) to develop. North Bay, ON P1B 5A4. CODING SPECIALIST Mackenzie Health - Richmond Hill, ON Monitor CIHI monthly and quarterly submission error reports to ensure abstracts are corrected and resubmitted. Health Information Management Professional Winnipeg Regional Health Authority - Manitoba Ability to apply CIHI standards and classification systems. Grow your career in the Winnipeg Health Region. Some of the benefits of working at CIHI include. Previous experience working with CIHI data is an asset. Some of the benefits of working at CIHI include. Enter your email address Sign Up To activate your job alert, please check your email and click the confirmation button. To activate your job alert, please check your email and click the confirmation button. You agree to get information about new jobs for this search by email. You can cancel email alerts at any time. SimplyHired may be compensated by these employers, helping keep SimplyHired free for jobseekers. SimplyHired ranks Job Ads based on a combination of employer bids and relevance, such as your search terms and other activity on SimplyHired. For more information, see the SimplyHired Privacy Policy. The Effects of Electrical Muscle Stimulation (EMS) towards Male Skeletal Muscle Mass.