ACC NCDR data collection by lab staff

Our lab collects ACC/NCDR information during a procedure. We created out own workup template and coordinated our EMR to gather all relevant data in one place. I created quite a few custom forms (we use MacLab) in order to meet the needs of the physician (for the procedure note/standardized reporting), the hospital as a whole (pharmacy, units receiving patient), and HIMS.

Our procedure record is checked for inventory/database/charge.

Hope this helps...

Thanks for sharing! You say you created your own template for ACC/NCDR info... does that mean that you don't use the pre-built ACC/NCDR forms in MacLab? I dislike the pre-built forms as they aren't well-formatted for ease of use, but custom forms won't automatically transfer to the ACC/NCDR module in the DMS. Is the ACC/NCDR data manually entered into a vendor program or the ACC/NCDR website for submission?

Another question... does the lab staff have easy access to all the data requested by ACC/NCDR? For example, our physicians aren't consistent in documenting in the H&P things like hx of asthma, prior CHF, if any anti-anginal meds in last two weeks. Stress testing is often only summed up as "positive stress test". To look up this info in the EMR means going to another computer terminal and scouring various other documentation (nursing notes, med rec forms, previous admissions, diagnostic tests, etc). The alternative is to code "no" whenever data isn't readily available or rely on physician memory on the spot, both options likely leading to missed background data.

Last question... does the lab staff accurately fill in interventional ACC/NCDR data such as % stenosis, TIMI flow, lesion complexity, etc? We don't use structured reporting (not yet, anyway) and the MacLab printout is anything but user-friendly, so the physician doesn't really review the MacLab printout (just signs off on the medications) and the dictation of the procedure often doesn't exactly match the MacLab notes. It's my understanding that physician documentation takes precedence in ACC/NCDR coding so the data entered by the staff has to be changed later anyway.

Thanks for any info!! I hear of lab staff being responsible for ACC/NCDR data and I wonder how they do it since ours is always so spotty. Maybe other places have better overall systems in place (more thorough H&Ps, more convenient EMR access, etc).