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Redesign the Paradigm: Efficient Clinical Documentation in an Electronic World Kristen Bates MBA, RHIA, CCS, CDIP Sue Ryan RN, CPAN, BSN Corporate Manager Health Information Services University Hospitals Quality Improvement Nurse Institute for Healthcare Quality & Innovation University Hospitals Case Medical Center Carol S. Gifford MSN, RN, CPHQ Kelly Skorepa BSN, RN, CCDS Quality Improvement Nurse Institute for Healthcare Quality & Innovation University Hospitals Case Medical Center Corporate Manager, Clinical Documentation Improvement University Hospitals Sara Hissong BS, RN Clinical Informatics Liaison, EMR Change Management Sally Streiber BS, MBA, CPC, CEMC Raymond Krncevic, Esq. Manager, Coding Compliance and Education, Compliance and Ethics Department University Hospitals Associate General Counsel Erica E Remer, MD, FACEP, CCDS Physician Clinical Documentation Education Coordinator University Hospitals Objectives • Identify bad documentation practices • Judge and generate superior clinical documentation • Assimilate electronic tips and tools to be more time efficient November 22, 2014 University Hospitals 2 Improving Documentation November 22, 2014 University Hospitals Improving Quality • Communication • Of medical care provided • Perception of outcomes November 22, 2014 University Hospitals November 22, 2014 University Hospitals Institutional Clinical Communication November 22, 2014 University Hospitals November 22, 2014 University Hospitals We’re going to cut and paste kids. Commas matter. November 22, 2014 University Hospitals Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Quality Assurance/Peer Review Report Privileged Pursuant to O.R.C. Section 2305.24, .251, .252 November 22, 2014 University Hospitals 9 ONE IS A MISTAKE; MORE IS A MESS November 22, 2014 University Hospitals Fact or Fiction? I don’t have time to document well November 22, 2014 University Hospitals Do you have time NOT to?! • Legal • Timing is everything • Internal inconsistencies • Right hand doesn’t know what the left hand is doing • Rationale • Lack of specificity November 22, 2014 University Hospitals Do you have time NOT to?! • Denials • Utilization Review • Clinical Documentation Integrity Queries • Audits November 22, 2014 University Hospitals Tell the Story! Substance is more important than length November 22, 2014 University Hospitals (Non) Progress note Service: Cardiology Subjective Data: is a 84 year old Female who is Hospital Day #6. Pt seen and examined at bedside. She has AD, poor historian. Pt appears comfortable. Overnight Events: Patient had an uneventful night. November 22, 2014 University Hospitals History? Chief Complaint: Patient comes in for a routine checkup F/U on DM and HTN; also c/o left sided chest pain History of Present Illness: Pt. has been notating his blood sugar for the past few weeks. Pt. came to discuss it with doctor. November 22, 2014 University Hospitals Daily Progress Note [ ] – for Visit: , Final, Entered, Signed in Full, General Subjective Data: is a 90 year old Female who is Hospital Day #2. Objective Data: November 22, 2014 University Hospitals November 22, 2014 University Hospitals Quality Assurance/Peer Review Report Privileged Pursuant to O.R.C. Section 2305.24, .251, .252 STOP THE BLOAT! November 22, 2014 University Hospitals 19 November 22, 2014 University Hospitals History? Chief Complaint: Chest pain History of Present Illness: 64 year old with history of previous MI 1999, c/o 1 week of intermittent achy 4/10 left sided chest pain with diaphoresis when walking his dog. Duration, Timing, Quality, Severity, Location, Associated signs and symptoms, Context November 22, 2014 University Hospitals November 22, 2014 University Hospitals yesterday morning. Patient to ask in the breakfast, and 80, and feel well. After taking at its. There are related off to know when he was sitting at the at the dinner table and his granddaughter was in his lab and he started feeling a lot of nausea, belching, Margaret abdominal pain, even to the bathroom 3 times yesterday. He was not work today, via he denies, fever, chills, sweating. November 22, 2014 University Hospitals 23 November 22, 2014 University Hospitals 5/28: ** Cardiomyopathy: - EF 25-30% on echocardiogram earlier in month - Re introduce hydralazine + will give 20 mg lasix IV once today - Will optimize HF meds 5/29: ** Cardiomyopathy: - EF 25-30% on echocardiogram earlier in month - Re introduce hydralazine + will give 20 mg lasix IV once today - Will optimize HF meds 5/30: ** Cardiomyopathy: - EF 25-30% on echocardiogram earlier in month - Re introduce hydralazine + will give 20 mg lasix IV once today - Will optimize HF meds November 22, 2014 University Hospitals Documentation (CMS) “May use macros,… but must provide customized info that is sufficient to support a medical necessity determination. ..must sufficiently describe the specific services furnished to the specific patient on the specific date. If both the resident and the teaching physician use only macros, this is considered insufficient documentation.” November 22, 2014 University Hospitals Don’t Propagate, Cogitate! Mindful Editing November 22, 2014 University Hospitals Good documentation What constitutes good documentation? November 22, 2014 University Hospitals Good documentation • Accurate, consistent • Relevant • Complete, but concise • Organized and easy to follow • Timely November 22, 2014 University Hospitals ED note, H&P, Consult Note • Timely • Original • Logical narrative • Appropriate detail • Pertinent positives, negatives, and abnormals • Support your conclusions November 22, 2014 University Hospitals Progress Notes • Timely • Don’t copy and paste from day to day • Don’t leave everyone wondering why is the patient still here (because nothing seems to be happening or changing) • Don’t let the only change from day to day, BE the day November 22, 2014 University Hospitals Office Notes • Have at least 1 chief complaint / reason for visit (not “follow-up,” not “no complaints”) • Address all chief complaints in HPI, ROS, and PE • Mindful editing of C&P or template from visit to visit • Support action plan November 22, 2014 University Hospitals AND IMPROVED November 22, 2014 University Hospitals Subsequent Hospital Days/Established Patient • (Hi)Story – What has happened? – How is the patient feeling? – Have the symptoms changed? – Any clinical events of note? • Observations (PE and testing) – Document your work-product – Make templates • Analysis and Plan (MDM) – Status (original problem, new issues) – Interpretation of tests, procedures – Medical necessity for new orders – Focus of treatment – Documentation of definitive diagnoses November 22, 2014 University Hospitals S O A P 34 Analysis & Plan • Most important part of the documentation • Don’t regurgitate the HPI or the interval history • Synthesize, analyze • Readable • Consultants need to be clear on recommendations • Evolving (progress notes). Don’t C&P the same assessment and plan every day. November 22, 2014 University Hospitals November 22, 2014 University Hospitals Analysis & Plan • Evolve diagnoses • Resolve diagnoses • Recap major diagnoses in discharge summary November 22, 2014 University Hospitals Don’t Attest, Invest! November 22, 2014 University Hospitals Attestation and Signature • An unsigned note is an unbillable service • Resident documentation without attestation is an unbillable service • Unattested and/or unsigned notes cannot be utilized to support any other service • The date of service can be adjusted if you are signing on a different day, presuming you SAW the patient on the earlier day November 22, 2014 University Hospitals Documentation Audit Tool 5 Chief Complaint Explicit Statement Historical Narrative Advances understanding of why patient is still in hospital PE PE appropriate to condition, accurate, identifiably unique Data Acquisition and Interpretation Appropriate testing, reviewed and analyzed Assessment (Diagnoses) Clear analysis and synthesis; all problems current with appropriate diagnoses Plan All identifiable problems with reasonable, clear plans; MDM commensurate with severity Attending Input Attending generated or additional added-value documentation and signed within 24 hours Succinctness No gratuitous C&P, no import of irrelevant info Accuracy Consistent w/ clinical picture, no incorrect info, mindfully edited, trustworthy Comprehensibility Understandable, organized, advances the story of the patient November 22, 2014 University Hospitals November 22, 2014 University Hospitals Ebbinghaus Curve of Forgetting November 22, 2014 University Hospitals Efficiency in the EMR November 22, 2014 University Hospitals Efficiency in the EMR • Technology – Have the technology work for YOU – Utilize your ancillary help (CC, PFSH, ROS) – Patient questionnaires (be sure to review, validate, sign and date, scan into record) – Dragon (Password) November 22, 2014 University Hospitals Don’t remove another disciplines’ content from a template November 22, 2014 University Hospitals Efficiency in the EMR • Acronyms – Acronym expansion in UHCare; Word macros for AEMR – You can incorporate other peoples’ acronym expansions November 22, 2014 University Hospitals Efficiency in the EMR November 22, 2014 University Hospitals Efficiency in the EMR • Acronyms – Acronym expansion in UHCare; Word macros for AEMR – You can incorporate other peoples’ acronym expansions • Favorites – Copying another clinician’s favorites in Problem List Manager • Can use CTRL+ Click, CTRL-Z and open document details of multiple documents at once November 22, 2014 University Hospitals Efficiency in the EMR • Build filters • Re-ordering orders • Utilizing “Favorites” (prescriptions, types of documents you use frequently) • To see old records, click “All available charts” and change the date range using “Authored Date” • Learn the meaning of icons – could add labels November 22, 2014 University Hospitals Efficiency in the EMR • Radio buttons: – All other systems have been reviewed… – Normals, My normal – Mindful editing November 22, 2014 University Hospitals UHCare Physician Support Line 216-286-6200 Available 24/7 November 22, 2014 University Hospitals Efficiency in the EMR November 22, 2014 University Hospitals Take-Away Points What did you learn and do you think would be valuable to pass on to others who weren’t present? November 22, 2014 University Hospitals Thank You. October 19, 2013 University Hospitals 55