That’s Bad Form!

1. That’s Bad Form! Michael Ben-Aderet, Tim Cushing, Derek Huang, Alvin Liu, John Sy, and Summer Williams

2. Why? • Too many forms • Forms need to be updated • Incomplete forms • Too many medical errors • Nurses paging housestaff about orders • Housestaff unsure about available options

3. Goals • Simplify Forms • Improve Patient Safety and Care • Improve Housestaff Satisfaction • Meet Government Requirements

4. Plan • Review all forms that housestaff use • Highlight necessary ones that need to be updated • Tackle those that are used the most

5. Old Cardiology Form (OV1399)From 2007 CLINICAL INFORMATION??? MEDICATIONS??? I‘M AN INTERN…HOW THE HECK SHOULD I KNOW WHAT TEST TO ORDER???

6. Process • Reviewed form with Cardiology Dept • Came up with form specifications: • Patient information • Name • Medications • HISTORY • Test information • Cardiology WILL change test depending upon clinical history and reason for exam

7. Form Cycle

8. To be smart? • What is a smart form? • A form that can be filled out online and/or printed • Improve legibility • Improve accuracy of information

9. Now, that’s a smart form…

10. New Cardiology Form (2013)

11. Review of Cardiology Form • Improved transfer of information to cardiology department • Enabled optimal testing to occur • Reduce exposure to unnecessary testing • No longer need old EKG form – especially as outpatient, just ask clerk to enter into system and patient should present OV card to cardiology department

12. Medicine Admission Form (OV2428) • Top 3 forms used by housestaff • Consistently being reviewed and updated • …but missing a lot • A comparison of forms: • OVMC – 3 pages • Harbor – 6 pages

13. Specifications • Each section of the form with different specifications depending upon the department involved… for example: Clerks, Phlebotomy, Laboratory Medical Administration, Patient Safety, JCHAO

14. Things we cannot change… • Handwriting – PLEASE WRITE LEGIBLY • Dosing errors – PLEASE CHECK YOUR RXs • That the RNs will STILL page you about your patient…

15. Old Order Form

16. Basic Information – Section 1 • ICU Added – no longer a separate form • Holdover box added – nurses know who to page (especially for hospitalist holdovers) • Admission location clear • Level of care change indication

17. Diagnosis and Assessment - Section 2 • Specified Isolation • What old chart??? • Don’t forget our neutropenic patients!

18. Physician Notification – Section 3 • What the heck is a SUPO Form? – JC requirement • STANDARD VITALS!!!  • Don’t forget to change them if needed!

19. Activity and Diet – Section 4 • Fluid restriction box

20. Consult and Treatment – Section 5 • Occupational Therapy • IV therapy: continuous vs fixed amount • Respiratory therapy • Chlorhexidine baths for patients on chemotherapy or with central venous catheters (CVCs) – for nursing

21. Labs/Test – Section 6 • More tests, especially for ICU • No more STAT labs – abuse of STAT power • Phlebotomy Information

22. VTE Prophylaxis – Section 7 • Meets all government requirements • Don’t forget to select a contraindication!

23. Medication Reconciliation – Section 8 • Start, continue, stop? • Don’t forget hold parameters and PRNs • Home medications MUST be listed in H&P

24. Typical Olive View Patient…

25. Common Medications – Section 9 • All those and more!... Night float will thank you for that Miralax! • GI prophylaxis • Prevent therapeutic duplication • Those pesky nebs!

26. Insulin – Section 10 • Can’t help you there… • But at least you don’t have to write “units”!

27. Pain medications – Section 11 • The pen is mighty…but checkboxes are easier! • I didn’t know we had (insert pain med here)! • What is that dose of IV dilaudid again? 2 mg?! • Avoid therapeutic duplication problem

28. Code Status – Section 12 • Only Attendings can sign DNR/DNI orders anyway…

29. New Order Form

30. Achievement Highlights • Eliminated ICU order form • Consistent vital signs for patient safety • Reduce use of STAT labs • Reduce therapeutic duplication • Encourage proper use of DVT and GI ppx • Eliminate confusion with med rec section • Brought in further commonly used medications

31. Assessment of New Form • Asked housestaff to fill out the old and new forms from a mock case • Timed themselves filling out both forms • Answered 5 questions based on old and new forms

34. Survey Results (n=5)

35. Committees • Both forms approved by MRRC (Medical Records Review Committee) • Admission Form must go to P&T committee to be approved (for medications) in early July • Will uploaded to the intranet for housestaff to use after P&T committee review

36. Ongoing activities… • Radiology form update • Nuclear Medicine form elimination • Insulin Form update

37. Acknowledgments • Dr. Mark Richman • Dr. Mike Rotblatt • Dr. Leland Powell • Dr. Susan Stein • Dr. Katherine Yu • Dr. Dennis Yick • Dr. Nick Kamangar • Dr. Robin Waschner • Anna Ziouzina • Laura Sarff • Karla Nungaray • Joy Mata • Lori Smith • Alma Alvarez • Jan Love • Carlos Carranza • Clerks • Nurses • Respiratory Therapy • Housestaff