Medical Residents Performance Enhancement Initiative

Documentation Improvement

Dr. Omer KhanTeam Leader Medical Residents

Proposal for Documentation Improvement Project @ SBAHC• Step 1: Demonstrate purpose of good documentation and

introduction to Clinical Documentation Improvement (CDI) • Step 2: Conducting needs assessment based on chart

reviews and understanding impact on key metrics• Step 3: Engage all physicians and create an effective CDI

Program city wide• Step 4: Develop a CDI Toolkit including e.g diagnoses

coding simplification, tip sheets, auto data entry and Trakcare-enabled physician guidelines in collaboration with IT and QM department

Problem Statement

Problem Statement

• While physicians, especially the medical residents generally work hard to ensure complete and accurate documentation, deficiencies do exist

• Inadequate documentation impacts both patient care and outcomes

Five C’ s

• Clear• Concise• Consistent• Current • Complete

Five C ‘s

• Clear, Concise, Consistent, Current and Complete documentation in the medical record is an essential component of quality patient care

The Wider Picture

• Medico-legally, documentation is regarded as the MOST essential element

• Failure to document relevant data is itself considered a significant breach of and deviation from the standard of care

However…..• Protection from legal jeopardy is far from the only

reason for documentation in clinical care. The patient's record provides the only enduring version of the care as it evolves over time

“The rule is simple: if you don’t write it down, it never happened.”

Other nice points why good documentation is needed

• The physician’s thought process is demonstrated through good documentation.

Being Clear and Logical

• The symptoms and physical findings on which a plan of care is based depends on clear and logical documentation

Good notes = Good work

• Good notes clearly document the facts of the situation and demonstrate thorough work.

• Inadequate notes Open to misinterpretation Unhelpful in providing care to the patient Unhelpful in demonstrating what took place.• Poor charting reflects less than sufficient attention

to detail and risks the conclusion that care was poor.

MEDICAL RESIDENTS P&Ps

POLICIES AND PROCEDURESSUBJECT: House Physician Patient Care Department/Service: Medical StaffPolicy No:MS-1.023Original Issue Date/Revision Date: February 2008 / March 2014

MEDICAL RESIDENTS P&Ps• PURPOSE:To provide the guidelines for house physician services for patients

care at Sultan Bin Abdulaziz Humanitarian City (The City).

• POLICY:Medical needs will be identified by initial assessments, and it will be

completed within established time frame i.e., 24 hrs. Assessment findings will be documented in the patient’s record and it will be available to those responsible for the patient’s care. All patients will be reassessed at appropriate intervals to determine their response to treatment and to plans for continued treatment or discharge

MEDICAL RESIDENTS P&Ps

PROCEDURES:• The house physician will provide the following according to

job description • Regardless of the patient’s source of referral or related

specialty the House Physician will assess the patient after admission in the unit within 2 hours or earlier depending upon the condition of the patient. History and physical examination will be documented within 24 hrs. The plan of care will be individualized and will be based on the patient’s initial assessment data

MEDICAL RESIDENTS P&Ps• The History and Physical examination will be completed by the

House Physician as outlined below within 24-hours of admission.

• Chief complaint• History of present Illness• Past medical history to understand the previous care rendered.• Current Medications, OTCs, supplements and herbal products • Social history• Family history• Pre-morbid functional status• Current Functional Status

MEDICAL RESIDENTS P&Ps• Review of systems

– General– Vital signs– Head/Eyes/Ears/Nose/Throat (HEENT)– Neck– Lungs– Cardiovascular– Abdomen– Extremities– Central nervous system– Skin

• Impression• Plan

MEDICAL RESIDENTS P&Ps

• House physician will make the initial diagnosis, differential diagnosis; identify the patient’s medical and nursing needs based on the history, physical examination and investigations.

• House physician will discuss the initial assessment with

the primary responsible physician. • Orders will be written when required and will follow

the organization policy.

POSITION DESCRIPTION / PERFORMANCE EVALUATION

INTERPERSONAL AND COMMUNICATION SKILLS:1. History &

Physicala. Completed

within 24 hours (100%)

a. Components included

Chief Complaint

• One sentence that covers the dominant reason(s) for hospitalization

• Ideally ,the complaints should have a time frame

Since 2007, for two years, since RTA

History of Present Illness (HPI)

• Should provide enough information without being too inclusive.

• Covers all events leading to the patient's arrival to the hospital

• It gets a bit tricky when writing up rehab patients with pre-existing illness(es) or a chronic, relapsing problem

Past Medical History• Includes any illness (past or present) for which the patient

has received treatment• Items which were noted in the HPI do not have to be re-

stated. You may simply write "See above" in reference to these events.

• All other historical information should be listed• Detailed descriptions are generally not required • Get in the habit of looking for the data that supports each

diagnosis that the patient is purported to have• All past surgeries should be listed, along with the rough date

when they occurred

Medications

Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage and frequency should be noted

Allergies/Reactions

Identify the specific reaction that occurred with each medication

Social History JCI observation during last visitBroad category which includes:• Cigarette smoking: Determine the number of packs used per day and

the number of years which the patient has smoked. When multiplied this is referred to as "pack years." If they have quit, make note of when this occurred.

• Alcohol Intake: Specify the type and quantity• Other Drug Use: Specify type, frequency and duration.• Marital Status:• Sexual History:• Work History (type, duration, exposures):• Other (e.g. travel, pets, hobbies):

Family History

• History of illnesses within the patient's immediate family.

• Cancer, coronary artery disease etc or other heritable diseases among first degree relatives.

Premorbid Functional Status

• Healthy/unwell• Any restrictions• Milestones

Current Functional Status

Review of Systems

• Most important ROS questioning (i.e. pertinent positives and negatives related to the chief complaint) is generally noted at the end of the HPI.

• The responses to a more extensive review which covers all organ systems are placed in this "ROS" area of the write-up.

• Tailor your documentation to the individual patient setting

Physical Exam

• Generally begins with a one sentence description of the patient's appearance

• Use the template provided• Tick the relevant boxes and provide details of

the findings

Impression/Diagnoses

• List all diagnoses, impressions, problem list

Plan

• Treatment plan• Admission for rehabilitation• Investigations (Baseline/additional)• Diet• Consultations• Added medications

The Final Touch

• Incorporate standards of capitalization, punctuation, syntax, and grammar

• Include only the approved abbreviations• Proof-read your notes

• And most importantly PLEASE AUTHORISE

• Issues?• Concerns?• Questions?