Documentation: Our Journey to the EHR (so far!)

 Laura Triplett, Director, HIM  Roseann Kilby, Clinical Informatics Analyst  Becky Crane, Clinical Risk Manager

367 Bed Community Health System in Quincy, Illinois 2,000 Employees 240+ Physicians Affiliates include:

- Illini Community Hospital (Critical Access Hospital in Pittsfield) - Community Outreach Clinic - Denman Medical Equipment - Denman Biomedical - Quincy Health Care Management - Blessing Physician Services

Schools of Nursing, Radiology and Laboratory

Our EMR…

 Blessing Hospital implemented Sunrise Clinical Manager in February of 2006  Blessing Automated Record, or “BAR”  Illini Community Hospital implemented Sunrise Clinical Manager in August of 2010 (ER documentation in 2008)  “Mini-BAR”  Steering committee utilized to select vendor  Committee was multi-disciplinary

Migration Strategy

 Orders, Results, Medication Administration Record, Nursing Worklists  Interdisciplinary Documentation & Dictated Documents  CPOE  Imaging System

Legal Medical Record Policy – Maintains the timing of implementations

Interdisciplinary Documentation

    Policy and Procedure: requirements for electronic documentation is the same as paper documentation.

Need policy for downtime procedures Electronic documentation enters date/time documentation occurs and by whom.   “Real time” documentation is highly encouraged Date/time columns are created by staff that designate the date/time the event occurred “WDL” - Within Defined limits-these items are defined per observation

WDL: hover over arrow for definition

Clinical Alerts

 Documents  Soft Stop: Blue exclamation mark observation is mandatory for the document to be considered complete.

!

- indicates this  Reminds staff upon saving that these observations are necessary for completion, allows staff to save as incomplete  Hard Stop: Red asterisk

*

- indicates this observation is mandatory for the document to be saved. Staff must complete the observation to save the document.

 All CAPS - indicates this observation is mandatory for the document to be considered complete.

Interdisciplinary Documentation

 Partnership with Clinical Practice Model Resource Center (CPMRC)  Knowledge Based Charting (KBC)-This included flow sheets and evidenced-based guidelines for the plan of care.

 Enter the appropriate guideline to the plan of care this pulls in appropriate interventions, patient education, and outcomes to the appropriate flowsheet

Clinical Alerts

 Flow sheets  Mandatory field is based upon completion of an observation  Example: documentation of pulse oximetry requires the observation for documentation for patient requirements of oxygen

Copy Forward/Auto Enter

 Documents have the capability to copy forward information from previous documents.  Flow sheets have the capability to auto enter information from previous documentation on that flowsheet.

 Staff are instructed that this is just a tool, that the information has to be verified with the patient that the information remains current.  Restrict what observations are allowed to copy forward/auto enter.

Copy Forward – Physician Documentation

Example…..

 History and Physicals done within 30 days of admission  Ability exists to copy forward  Copying electronically makes it difficult to determine when the original was created  Recommend adding statement to copied forward document indicating that it isn’t an original

"This document was copied forward from H&P, dated XXXX, visit XXXX. Please see additional update for this visit, XXXX, by Dr. XXXX, the attending of record."

Reports

 1.

2.

3.

4.

5.

Test and Validate – our strategy Create Report Test using a fake patient Copy production environment Test report with real patient data After validation, move to production environment

What you document in the system may not look the same when printed

Downtime Processes

 Locally stored on downtime PC’s every 15 min.

 Hard copies of downtime forms  Backload documentation  Medications   Orders Tasks  Depending on duration of downtime

BAR Change Control Policy

 Requests for new or revised changes  CIS Change Request Form  Requests for changes to MLM’s* or reports  MLM Request Form or Report Request Form   Forwarded to care delivery redesign Changes made monthly unless emergent  *Medical Logic Model

Documentation

 Legal record of care delivered  Communication mechanism between HCP’s of IDT  Goal: interdisciplinary, patient-focused, non duplicative, individualized, concise and meaningful  Clinical Practice Guidelines used as part of POC  Interdisciplinary Education Record  Point of Care / Concurrent Charting

Frequency of Charting

 Systems Assessment by RN on Assessment/Interven tion flowsheet every 24h  Daily between hours of 7am-3pm   Change in condition, response to care, & transfers in level of care are documented throughout the day  Focused Assessment / Reassessment by RN  Between hours of 3pm-7am and as warranted by a change in condition Outcome statement completed each shift by RN  Each episode of teaching & pt/family response on Education Outcome Record by IDT  Additional flowsheets used as needed

Examples of Flowsheets

            Behavior/suicide CAPD Exchange Record CIWA Diabetes/Glucometer Mental Status Assessment Neuro Assessment NIH Stroke Scale Nutritional Care Priority Patient Controlled Analgesia Respiratory Therapy Restraint Roto-Rest Bed

Pros & Cons of EHR

 Legible  Concise  Content guided by design to meet legal requirements; much like the “T-sheets” in the ED  Lose the story-telling aspect; fragmented  Printed version doesn’t look like electronic version  Check for accuracy

How to “Tell the Story”

  Outcome – Evaluation document

14. Adult Guideline Assess/Outcome Eval [7-Jul-2011 01:37] ,

Visit: 1188, Nurse, Nancy (RN) [Signed: 7-Jul-2011 04:34] ,

Complete, Entered, Signed in Full, General

Summary Statement : Alert/oriented. Wearing bi-pap at night and ET CO2 monitor. At times respirations were down to 9, held dilaudid until in teens. States is having urinary hesitency and feeling as if he is not empying bladder. Did bladder scan which showed no residual. Wife in room all night with him. C/O pain 5/10 to bilateral arms and back @ worst, 2/10 following dilaudid. No other complications.

How to “Tell the Story”

Item from pick list must be selected in order for header to be visible on printed report.

 In this example, the nurse manually typed in “intermittent” under grunting and “slight” under intercostal retraction.

In the first column, the nurse manually typed in “L” and “FiO2”. In the second column, the nurse did not. When printed out, only the numbers appear – see next slide

Printed flowsheet. What do the numbers indicate?

Documentation faux pas

  Words like “Accidentally” or “Somehow” Unit / staffing issues  Request for 1:1    Criticizing the Patient  “Patient is obviously not in as much pain as she says she is.”  What wasn’t done or Ordered  Fetal heart tones not assessed this shift Criticizing Care of Others  Cooling blanket improperly applied by previous shift Mention of Incident Report  “Notified risk management, and occurrence report completed.”

Metadata

 Data about data  Hidden attributes for individual file including name, dates, alterations, deletion, who accessed & from where  Includes e-mail information: header, blind carbon copy recipients, etc.

Litigation, Threat of Litigation, Legal Action or Investigation

 Remove chart from normal use to preserve in original state  Capture electronic data ASAP  Suspend routine destruction or disposition of records  Preserve all relevant records regardless of form

 Importance in a lawsuit cannot be over-emphasized  If factual, consistent, timely & complete - our best DEFENSE  “If it isn’t documented, it wasn’t done.”  Document observations, action, treatment and outcome of care YOU provided A plaintiff’s attorney has 2 years* to thoroughly review the chart for errors and omissions.

WDL?

 Medication order was entered, verified by pharmacy and administered by nursing/signed off as 1500 grams of Vancomycin…  Patient was charged $79,181.10

Timely Documentation

 Failing to document real time could result in suspicion   E.g.: Documentation that occurred hours after pt death

Paint A Clear Picture

 Example: midnight documentation  “pt stable, vs good, plan discharge tomorrow.”  3:30 am documentation of pt death.

Requests for records

 Volume  Admission paperwork 23 pages in EHR  One day documentation – random – 46 pages  Largest request for records 8000+ pages ($2,500)  Disc Format used more & more

In Summary

 Blessing’s Journey to the EMR  A few Lessons Learned  Some Do’s & Don’ts  Any suggestions, comments or questions?