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🌱 Answer: All patients should have Long Term Outcomes entered. If the patient has a non-burn injury such as friction/ road rash, you should complete the data point.
🤔 Question: A was patient admitted to burn service for a burn injury, but surgery is done by another service (i.e. hand surgery done by the hand surgery service) and then at the time of discharge they follow-up in the same hospital system, but not burn clinic - would this be lost to follow up or follow-up complete?
🌱 Answer: If the patient is discharged from the Burn Service and does not follow up in the Burn Service clinic but still need burn follow up, then they are Lost to Follow Up. If the patient is discharged and it is determined by the burn service that they no longer require any burn follow up, then their Follow up is Complete. You may need to ask you burn team which selection is appropriate.
🤔 Question: What if patient died during their hospital stay and won't have LTO? Ok to leave screens blank?
🌱 Answer: Yes, you should not enter LTOs on any patient that died as an inpatient.
🤔 Question: If a patient has an appointment in the burn clinic but "no shows," should they put that in as an LTO encounter and just put ND in all the fields?
🌱 Answer:
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No, if they don’t show up, don’t put in as an encounter. Only enter encounters when they show up to appointments.
Date of 95% Wound Closure
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🌱 Answer: No, this field is only required for burn patients. The next update of the Data Dictionary will reflect this but for the time being, only record this information for burn patients and click "Not applicable" for patient with inhalation injury or non-burn patients.
🤔 Question: On data dictionary page for 95% wound closure (page 147), it gives us the field value of "Not known/Not recorded" but that option is not available in BCQP. I only see a date field or Not applicable. What do we use in BCQP for Not known/Not recorded?
🌱 Answer: For now, just leave it blank. We will discuss this with BData.
🤔 Question: If you have a patient that was discharged and will follow up at another burn center closer to their home, what should you document for the LTO - Closure and Procedures tab for: Date of 95% wound closure? - Not applicable since they aren't following in your burn center? and Follow-status? - Lost to follow up?
🌱 Answer: You should leave the 95% wound closure field blank, if the wound was not 95% closed at your facility, either before they were discharged or after if you are seeing them in your clinic. You would select "Lost to Follow Up" for follow up status.
Outpatient Follow Up Status
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🌱 Answer: Long Term Outcomes are collected for 12 months from the time of the patient's initial discharge.
🤔 Question: What should be entered when a patient that has an inhalation injury is discharged and does not require any follow up in the burn clinic? Would it be "follow up complete" even though they did not have any follow up? What about when their follow up is with their PCP?
🌱 Answer: Yes, it would be Follow Up Complete because, from the Burn Center's point of view, the patient does not require any further follow up for their burn. If they do require follow up for their burn, but this is referred to their PCP, enter Lost to Follow Up.
🤔 Question: A burn patient followed up at our outpatient clinic for 2 months after discharge, then moved to another state for continued follow-up. What should be selected for the follow-up status: "continue," "complete," or "lost to follow-up"?
🌱 Answer: Lost to Follow-up if the patient still requires follow-up care for the burn injury but is being sent to a different facility for continued care. This is not a negative statement as many burn centers send their patient to other facilities for follow-up care if they live a distance away.
Operative or Outpatient Procedure Date
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🌱 Answer: ASD and PTSD must be diagnosed by a medical professional, depression may be either by patient/parent report or medical professional. A screening tool may be used to document depression, but not ASD/PTSD. No, you do not have to do this every visit and if you don’t for a selected visit, select “Not Documented in Outpatient Record”.
Operative or Outpatient Procedure Type
Operative or Outpatient Procedure Location
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Date of Outpatient Visit
🤔 Question: Is every LTO visit being recorded for a defined period of time or based on a triggering event?
🌱 Answer: Record every outpatient visit for the first 12 months post-discharge.
Scar Appearance Evaluated
Scar Assessment
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🤔 Question: What should be entered for clinic evaluations on patients that come into the clinic daily for dressing changes?
🌱 Answer: The decision about which clinic visits to enter is up to the burn center. If the patient is coming in daily for dressing changes, you may decide to only enter a weekly clinic visit to capture how the patient is doing. The intent here is to obtain long term follow up data on those variables in the clinic evaluation section, and if the data is not changing from daily visit to daily visit, you may decide not to enter each daily visit.
Scar Appearance Evaluated
🤔 Question: For the LTO scar appearance evaluated field, there are only two options - yes or not documented. What if the patient's burn is still acute and there's no scar formation yet? I feel like "not documented" doesn't necessarily reflect what's happening, since there's no scar to evaluate yet.
🌱 Answer: This is currently being reviewed by the Data Definitions Workgroup. For now, if there are no scar to evaluate, leave this blank.
Patient has Return to Pre-Burn Injury Activities
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🌱 Answer: Yes, that’s correct. Yes, it’s whatever the patient/parent considers fully returned to pre-burn activities.
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Presence of Post-traumatic Stress Disorder (PTSD)
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🌱 Answer: A medical professional can document the presence of PTSD or ASD - a psychologist or psychiatrist should be involved in the diagnosis of these conditions.
🤔 Question: For the data points PTSD and ASD - what is the different between "yes-screening tool" and "yes-documented"?
🌱 Answer: If the clinic is using a screening tool to evaluate these data points, then check “yes – based on screening during clinic” field value. If the clinic note references health professional documentation of PTSD or ASD, but no specific screening tool is mentioned in the chart, then check “yes- based on documentation in chart”.
Question: Can you add N/A on the LTO - Evaluation section for PTSD follow up? Our pediatric patients don’t get screened for PTSD.
🌱 Answer: No, if you don't screen, then click "Not documented in Outpatient Record".
Question: In LTOs, does the mental health diagnoses for PTSD and ASD need to be documented in the clinic notes or can we take the diagnosis from an inpatient note?
🌱 Answer: For the Data Points on PTSD and ASD, the initial documentation can be in the inpatient note but should also be documented in the outpatient note if the condition is still present.
Presence of Acute Stress Disorder
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🌱 Answer: Please select "Yes, requiring over the counter pain medication" for those patients who say they have pain but are not taking any pain medication.
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