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QUALITY OF DOCUMENTATION IN MEDICAL RECORDS. NYCHSRO’s Experience in Title I Quality Management Review. New York County Health Services Review Organization Harriet Starr Vice President, Government Contracts. ISSUES IN THE QUALITY OF MEDICAL RECORD DOCUMENTATION.

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quality of documentation in medical records

QUALITY OF DOCUMENTATION IN MEDICAL RECORDS

NYCHSRO’s Experience in

Title I Quality Management Review

New York County Health Services Review Organization

Harriet Starr

Vice President, Government Contracts

issues in the quality of medical record documentation
ISSUES IN THE QUALITY OF MEDICAL RECORD DOCUMENTATION
  • Timely and accurate documentation is

associated with:

    • improved quality of care
    • seamless continuity of care
    • enhanced ability to demonstrate equitable delivery of service and improved outcomes
    • streamlined work processes
    • reduction in the duplication of work
    • reliable data sources
    • increased client, worker and payer satisfaction
issues in the quality of medical record documentation1
ISSUES IN THE QUALITY OF MEDICAL RECORD DOCUMENTATION
  • Problems with documentation are reflected in lower scores on quality indicators
    • Quality of care may appear worse than actual
new york county health services review organization nychsro
NEW YORK COUNTY HEALTH SERVICES REVIEW ORGANIZATION (NYCHSRO)
  • Review agent for AIDS Institute Title I Quality Management Program since 2001
  • Reviewed the following programs:
    • Case Management
    • Treatment Adherence
    • Food and Nutrition
    • Home Care
    • TB DOT
    • currently reviewing Harm Reduction
nychsro s experience
NYCHSRO’s EXPERIENCE
  • Reviewed approximately
    • 2700 records at 74 programs in 2005
    • 2900 records at 44 programs in 2006
      • 5600 in last 2 years
nychsro s experience continued
NYCHSRO’s EXPERIENCE(continued)
  • Observations about the quality of documentation in medical records
    • Based on reviewers’ impressions on completion of a facility’s reviews
    • Taken mainly from 2005 Food & Nutrition reviews (850 records at 14 providers) and 2006 Case Management review (2700 records at 31 providers)
    • Findings are representative of 1/3 to 1/2 of records at nearly half of the providers
observations
OBSERVATIONS
  • Critical information not documented
    • Lists of community food and nutrition services provided at intake, automatically or on request, but not documented in client record
    • No documentation for months at a time. Was client disenrolled from program?
observations1
OBSERVATIONS
  • Documentation not dated
    • Dates of primary care physician visits, lab values (CD4 counts and Viral Loads), and lists of ARV medications missing
    • PCP appointments discussed in progress notes, but dates of appointments not documented
    • Photocopies of PCP appointment cards lacked year of service
    • Progress notes not dated
observations2
OBSERVATIONS
  • Disorganized record
    • Difficult to locate demographics and follow-up assessments, particularly of client weight and HIV medications
    • Progress notes not sequential
    • CD4 and Viral Load values found in different location than dates of these tests
observations3
OBSERVATIONS
  • Incomplete record; documentation stored in too many places
    • Dates of educational sessions stored in different location than topic
    • Intake information only kept in oldest of multiple charts
observations4
OBSERVATIONS
  • Incomplete record; documentation stored in too many places (continued)
    • Primary care data (HIV medications, PCP visits, CD4, viral load) stored only in charts from other programs (e.g., Case Management) and not in Food & Nutrition chart
    • Demographics only in URS, not in chart
observations5
OBSERVATIONS
  • Documentation is too general
    • Schedule of educationalsessions provided; no topic available
    • Topic of educational session identified only as education
observations6
OBSERVATIONS
  • Documentation is too general (continued)
    • Client need identified as entitlement; no clarification as to whether need was for food stamps, ADAP, Medicaid, etc.
    • Unable to distinguish between client’s primary medical care and mental health visits
observations7
OBSERVATIONS
  • Documentation is illegible
    • Illegible handwriting in notes
    • Can’t identify provider; can’t read signature
    • Photocopies too light or smeared/distorted
    • 3rd or 4th copy of multipart form; nothing legible
observations8
OBSERVATIONS
  • Inconsistencies among documentation
    • Client referred to case manager for assistance with housing, but no documentation that housing status was assessed
    • Case management assessment and service plan differ as to clients needs. Assessment may indicate “no need identified” in a particular area, but this need addressed in service plan.
    • Goals for client identified then dropped
observations9
OBSERVATIONS
  • Successful Strategies
    • Documentation is handled as if third party, unfamiliar with agency, will be reading it
    • Charts are structured to systematically follow the service delivery and standard of care
    • Use of forms and flow charts for intake, assessment, primary care indicators
    • Uniform training and policy for documentation
    • Electronic medical record – addresses issues of legibility and organization