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Medical Documentation Improvement Initiative

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Omer Khan
Omer Khan

The document proposes an initiative to improve medical resident documentation at SBAHC. It outlines a 4-step plan: 1) demonstrate the purpose of good documentation; 2) conduct a needs assessment; 3) engage physicians in a clinical documentation improvement program; 4) develop documentation tools. The initiative aims to address deficiencies in documentation, which impacts patient care and outcomes. Good documentation is important for quality care, legal protection, and demonstrating the care provided. The proposal also includes policies and procedures for house physician patient care responsibilities, including conducting assessments and documenting findings.

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Medical Residents Performance Enhancement Initiative Documentation Improvement Dr. Omer Khan Team 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 dont write it down, it never happened.
Other nice points why good documentation is needed The physicians 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 Documentation Improvement Initiative
MEDICAL RESIDENTS P&Ps POLICIES AND PROCEDURES SUBJECT: House Physician Patient Care Department/Service: Medical Staff Policy No:MS-1.023 Original 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 patients record and it will be available to those responsible for the patients 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 patients 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 patients 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 patients 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.
Medical Documentation Improvement Initiative
POSITION DESCRIPTION / PERFORMANCE EVALUATION INTERPERSONAL AND COMMUNICATION SKILLS: 1. History & Physical a. 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 visit Broad 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?

More Related Content

Medical Documentation Improvement Initiative

  • 1. Medical Residents Performance Enhancement Initiative Documentation Improvement Dr. Omer Khan Team Leader Medical Residents
  • 2. 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
  • 4. 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
  • 5. Five C s Clear Concise Consistent Current Complete
  • 6. Five C s Clear, Concise, Consistent, Current and Complete documentation in the medical record is an essential component of quality patient care
  • 7. 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
  • 8. The rule is simple: if you dont write it down, it never happened.
  • 9. Other nice points why good documentation is needed The physicians thought process is demonstrated through good documentation.
  • 10. Being Clear and Logical The symptoms and physical findings on which a plan of care is based depends on clear and logical documentation
  • 11. 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.
  • 13. MEDICAL RESIDENTS P&Ps POLICIES AND PROCEDURES SUBJECT: House Physician Patient Care Department/Service: Medical Staff Policy No:MS-1.023 Original Issue Date/Revision Date: February 2008 / March 2014
  • 14. 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 patients record and it will be available to those responsible for the patients care. All patients will be reassessed at appropriate intervals to determine their response to treatment and to plans for continued treatment or discharge
  • 15. MEDICAL RESIDENTS P&Ps PROCEDURES: The house physician will provide the following according to job description Regardless of the patients 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 patients initial assessment data
  • 16. 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
  • 17. 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
  • 18. MEDICAL RESIDENTS P&Ps House physician will make the initial diagnosis, differential diagnosis; identify the patients 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.
  • 20. POSITION DESCRIPTION / PERFORMANCE EVALUATION INTERPERSONAL AND COMMUNICATION SKILLS: 1. History & Physical a. Completed within 24 hours (100%) a. Components included
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. Medications Includes all currently prescribed medications as well as over the counter and non- traditional therapies. Dosage and frequency should be noted
  • 25. Allergies/Reactions Identify the specific reaction that occurred with each medication
  • 26. Social History JCI observation during last visit Broad 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):
  • 27. Family History History of illnesses within the patient's immediate family. Cancer, coronary artery disease etc or other heritable diseases among first degree relatives.
  • 28. Premorbid Functional Status Healthy/unwell Any restrictions Milestones
  • 30. 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
  • 31. 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
  • 32. Impression/Diagnoses List all diagnoses, impressions, problem list
  • 33. Plan Treatment plan Admission for rehabilitation Investigations (Baseline/additional) Diet Consultations Added medications
  • 34. 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
  • 35. Issues? Concerns? Questions?