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Department of Medicine Performance Improvement Record Completion
Regulatory Background • DOH, The Joint Commission and TUH MS Bylaws require record completion w/in 30 days of discharge. • Any incomplete record > 30 days is considered Delinquent. • TJC & DOH require monitoring and reporting of delinquent records.
DOM & MRD: Joint Efforts • Early process developed w/ DOM Chief Dr. Karen Lin • Ongoing weekly communication with Chief Residents regarding delinquent residents. • MRD paging of delinquent residents. • Chiefs direct communication with delinquent residents. • Goal: decrease need for MIS suspension.
Technology Enhancements • 1/07 Implementation of electronic record completion module in Alpha Imaging. • Physician direct access to incomplete record lists via Alpha sign-on. • e-Sign capability. • Auto e-mail notification of outstanding records. • “waiting for Dr… to dictate” upgrade.
DC Summary: Next Steps • DC Summary simplification process for short stay cases (< 5 day LOS) • Joint CHF Workgroup and Medical Record Committee Recommendation • Address CHF CORE DC medication documentation requirements • Developed with DOM Chief Residents
MIS DC Summary/DC Instruction • MIS template document created & resident completes for discharge: DC instructions. DC Summary (<5 day LOS). • Auto fax to PCP. • Signed by attending physician and complete record without further dictation. • DC summary dictation still required for LOS 5 day and greater. • Anticipated transcription savings: $52 K per year --3 & 4 day LOS - 23% volume.