The Patient Registry contains a master list of all of the clients in your community who have Type 2 diabetes. It also stores data about how well the client’s diabetes is being managed, what tests he or she has had, and what medications have been prescribed.
The Registry sits in a software package called Microsoft Access, which is used for databases.
The Registry is one of the most important tools in this project. It makes sure we track each individual client so that no one falls through the cracks. The Registry will help us make sure that clients get follow-up visits when they need them, and that they get certain tests done every 3 months or every year, according to clinical guidelines. The registry also helps us identify which clients are struggling to control their diabetes and are in greatest need. CHWs can then devote more time to support these clients with the greatest need to better manage their care.
Your task as a CHW will be to enter data on clients with diabetes using standardized forms in the registry, and print off reports that can be either put in clients’ chart and/or discussed as a group between yourself, the doctor and nurse. These reports are very important as they help everyone keep track of the care provided to each client and to see how the clinic is doing overall.
Each community should designate an individual responsible for entering data. This could be all of the CHWs, or only certain ones. Each community should also designate who else has access to the Registry (e.g., nurse-in-charge).
Each CHW involved in using the Registry should read the privacy and confidentiality guidelines.
Each clinic should have designated folders where incoming lab results and recently completed CHW Diabetes Clinical Assessment Log Sheets can be stored temporarily until the information from these sheets can be entered into the Registry. These folders should be stored in a secure area (e.g., locked cabinet).
There are three types of forms in the Registry for entering data:
- the patient demographics form, which is filled out just once for each new diabetes client;
- The patient visit form, which is filled out after each client visit.
- The lab form, which tracks latest lab results.
The reports that can be printed from the Registry include:
- Patient list
- Latest results
- Recall list
Identifying clients with Type 2 diabetes for the first time
1. Review existing lists of diabetes clients. Most clinics will have some pre-existing list of diabetes clients. The CHW should sit down with the head nurse, review the list and think of any additional clients that should be added. If there appear to be some clients missing, the nurse can pull the chart, look to see if each client has diabetes (best definition, at least one A1C reading >= 6.5), and then add the clients to the list.
2. The nurse then provides the CHW with information about the name, OHIP number, date of birth and band number of each client.
3. The CHW then enters the key personal information about each client into the Registry. First, open the Microsoft Access file that will be put on the desktop of your computer. Look at the vertical menu on the left side, look for “Data Entry Forms”, and select “Patient”. You will then have a form where you can enter new patient data.
4. After you have entered all the names that the nurse has given you, print out a copy of the master list of clients from Access. It will look something like this:
5. Fax this list to the medical secretary assigned to your community. Ask her/him to verify that all of the information matches EXACTLY what is found in the OSCAR electronic medical record (EMR). If something is different, check with the client about what is most correct. You should go with whatever is written on the client’s official government ID card (e.g. OHIP Health Card). If the paper chart does not match the OHIP card, then ask the nurse to change this information in the paper chart. If the OSCAR record does not match the government ID, then report this to the medical secretary and ask him/her to change it.
6. Over the next month, ask the nurse to check each client coming to the clinic to see if that client actually has diabetes and was somehow omitted from the list. Add any additional clients to the registry as described above.
Entering Lab Data
1. Lab results on paper are sent from the lab to the clinic, and typically go first to the nurse-in-charge.
2. The nurse flags lab results for clients known to have diabetes and puts them aside in a special folder.
3. Once a week, the CHW will take the lab results in the folder and enter them into the database. The following is the data entry form in the database used for this purpose:
4. After lab data has been entered, the CHW should initial the lab form and write “entered into database” and put the lab form in a different designated folder so that it can be filed by the person in the clinic responsible for filing.
In the future, we hope that lab data will be automatically transferred to the registry from the OSCAR medical record and that this process can be eliminated.
Entering Data from Each Visit
After each routine follow-up visit, information about blood sugar, weight, medication use, and glucometer use will be entered into the registry.
1. Each CHW should complete a CHW Diabetes Clinical Assessment Log Sheet (see below) during each client visit. After the visit, the sheet should go into a designated file folder for sheets waiting to be entered into the Registry.
2. The CHW designated to use the Registry should enter data from these sheets into the “Visit Info” form in Access. To open this form, double-click on the “Visit Info” tab on the left side of the screen, and the form should then pop up.
3. Enter information in each section of the standard form. It is OK for you to skip a particular section if there is nothing new to report or ask about. If possible, the CHW should enter these sheets at the end of each week, and all forms must be entered before each team meeting (see below).
4. After the data have been entered, the CHW should initial at the bottom of the back page of the Log sheet indicating that data have been entered. The Log sheet should then be archived into a binder in a locked storage area. (Alternatively, a community may choose to keep the sheet in the client’s chart.)
1. Click on the tab for the “Latest Results” Report on the left side of the Registry to open this report. Print off a copy. Share this for use in team meetings for organizing client care (see section I).
This is what the report looks like. Indicators marked with a single star (*) are slightly worse than normal, two stars (**) are worse than normal and three stars (***) are very abnormal:
2. Click on the tab for the “Recall Results” Report on the left side of the Registry to open this report. Print off a copy. Share this for use in recalling clients to the clinic (see section H).
This is what the report looks like. Clients with a single star (*) will soon be overdue for the test. Clients with two stars (**) are already overdue.
3. Click on the tab for the “Client List” Report on the left side of the Registry to open this report. Print off a copy. Share this with the doctors and nurses periodically (e.g. once a month) and ask if the list is complete and if any new diabetes clients should be added.
Download or use this online CHW sample form to practice the contents of this module.
Please note that these training modules are to be used for the purposes of CHW training in diabetes management. CHWConnect does not provide medical advice or specific diagnostic or treatment information.