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🌱 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: 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: 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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