CC-UC-02700 - Emergency Department: Basic Flow - Laboratory

Actors

• Patient/Patient Caregiver
• Registered Nurse (RN)
• Emergency department Medical Doctor (MD)
• Phlebotomist
• Laboratory technician
• Consulting Specialist

Pre-conditions

• The patient arrives at the Emergency department (ED) and is concerned with the onset of new symptoms.
• The patient symptoms resemble septic shock.
• The patient is covered by provincial/territorial health care insurance.

Step	Description	Data elements collected	Result
1	The RN orders investigations to address the symptoms of the health concern. Investigations and treatment may may include but are not limited to chest x-ray, urine culture, urinalysis, blood cell count, intravenous fluids, acetaminophen/ibuprofen.	Service Request Identifier Service Request Category Service Request Name Service Request Reason Service Request Intent Service Request Status Service Request Urgency Service Request Timing (if applicable) Service Request Additional Instructions Service Requester Service Request Date and Time Authored On Service Request Performer Service Request Performer Type (if specified) Medication Medication Dose Value Medication Dose Unit of Measure Medication Route of Administration Medication Reason Medication Request Intent Medication Request Authored on Date and Time Medication Request Priority Medication Request Status	The requested investigations and treatments are ordered, and the patient's medical record is updated to reflect the orders.
2	The phlebotomist collects the specimen and they are sent to the lab for processing by the laboratory technician .	Specimen Collection Organization Specimen Identifier Specimen Processing Status Date and Time Specimen Lifecycle Stage Specimen Status Specimen Type Specimen Collection Period Specimen Collection Body Site Specimen Collection Procedure Specimen Handling Instructions	Patient specimens are collected and sent to the laboratory for processing, and the patient's medical record is updated.
3	The medical doctor ( MD ) validates the health concern described by the patient.	Health concern(s) Health Concern(s) Health Concern Body Site Health Concern Severity Health Concern Evidence Health Concern Date of Onset Health Concern Date of Resolution Health Concern Date of Diagnosis Health Concern Clinical Status Health Concern Category Health Concern Verification Status Health Concern Reporting Source	The health concern is validated, and the patient's medical record is updated.
4	The MD evaluates the health concern and addresses the patient's symptoms sepsis.	Health concern(s) Health Concern(s) Health Concern Body Site Health Concern Severity Health Concern Evidence Health Concern Date of Onset Health Concern Date of Resolution Health Concern Date of Diagnosis Health Concern Clinical Status Health Concern Category Health Concern Verification Status Health Concern Reporting Source	The patient's health concern is evaluated, and sepsis symptoms are addressed and the patient's medical record is updated.
5	The MD initiates sepsis protocols and orders additional blood work. Sepsis protocols may include but is not limited to; ordering blood cultures, ordering additional blood work and initiates treatment. (e.g. antibiotics).	Health Concern(s) Service Request Identifier Service Request Category Service Request Name Service Request Reason Service Request Intent Service Request Status Service Request Urgency Service Request Timing Service Request Additional Instructions Service Requester Service Request Date and Time Authored On Medication; Medication Dose Value Medication Dose Unit of Measure Medication Route of Administration Medication Timing Medication Reason Medication Request Intent Medication Request Authored on Date and Time Medication Request Priority Medication Request Status Medication Administration Status (if treatment is actually given) Medication Administration Role Type Medication Administration Date and Time	Sepsis protocols are initiated, additional laboratory investigations are ordered, and the patient's medical record is updated to reflect the care plan.
6	The MD/RN monitors the patient and assesses their response to initial treatment.	Date and Time of Observation Measurement Type Unit of Measure Body Temperature Blood Pressure Blood Pressure Measurement Method Blood Pressure Measurement Body Site Blood Pressure Measurement Body Position Heart Rate Heart Rhythm (if assessed) Respiratory Rate Pulse Oximetry Health Concern Severity Health Concern Clinical Status Medication Administration Status Medication Administration Date and Time	The patient's response to initial treatment is assessed, and the patient's medical record is updated.
7	The MD consults the appropriate services in support of the patient's treatment plan. (e.g. general internal medicine MDs etc.)	Service Request Identifier Service Request Category Service Request Name Service Request Reason Service Request Intent Service Request Status Consultation/Referral Type Service Request Urgency Service Requester Service Request Date and Time Authored On Service Request Communication Method Service Request Supporting Documentation Service Request Performer Service Request Performer Type Health Care Provider Specialty and Subspecialty Health Care Provider Role	Appropriate services are consulted in support of the patient's treatment plan and the patient's medical record is updated.
8	The MD consults with the appropriate consulting specialist , who recommends admission to the Intensive Care Unit (ICU) and patient is transferred to ICU.	Service Request Status Service Request Status Reason (if applicable) Health Care Provider Specialty and Subspecialty Health Care Provider Role Care Team Member Information Care Team Member Role Care Team Member Period Encounter Status Encounter End Date and Time (if the current encounter/phase closes) Encounter Disposition Encounter Category Encounter Type Encounter Organization Organization Identifier Organization Name Organization Type	The patient is admitted and transferred to the Intensive Care Unit (ICU), and the patient's medical record is updated to reflect the transfer of care. The patient is admitted as a ward in-patient. CC-UC-02800 Hospital In-Patient Basic Flow
9	This use case ends.	Not applicable	Not applicable

Post-conditions

• The patient's health concern is addressed and treatment is started.
• Investigations and treatments are ordered.
• Appropriate services and specialists are consulted in support of the patient's treatment plan.
• The patient is admitted and transferred to the Intensive Care Unit (ICU).
• The patient's medical record is updated.

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