Dispelling Bad Documentation Habits in Clinicians Early

1. Dispelling Bad Documentation Habits in Clinicians Early Michelle Leeding – Health Information Manager Debbie Tansacha – Medical Education Officer

2. The Journey

3. Overview • Setting the scene • Background rationale • Medical Education Unit • Intern Program • Lessons Learnt • Where to from here?

4. Setting the Scene

5. Setting the Scene

6. Background Rationale • Recommendation from Coroner’s Report • Establishment of new HIMS position • Improvement of Intern Orientation program

7. Background Rationale Background Rationale • Coroner’s Report Black, T,J. 2008. Inquest into the cause and circumstances surrounding the death of Kenneth Maggable on 9 August 2005, Findings.

8. Background Rationale Background Rationale • Health Information Management Service • Medical Education Unit

9. Medical Education Unit Medical Education Unit Role: Coordinates the education and training of Resident Medical Officers (Intern to PHO) within Redcliffe Hospital in line with accreditation standards and medical registration regulations

10. Intern Program: Phases • Orientation / debrief • End of Term Audits • End of Term Reports / Statistics • End of Term Interview process • Mid year group results • End of year comparative analysis

11. Intern Program: Orientation

12. Case Study 1 Mabel Smith: 79yo female Admitted to Orthopaedic Ward Fractured Neck of Femur Initial pain relief in ED PMH: Ischaemic Heart Disease, Type II Diabetes SxH: Widowed, lives alone Allergy: Cephalexin

13. Case Study 1: Tasks TASK 1: Write up the admission progress notes in the chart provided TASK 2: Write up Medication Chart TASK 3: Complete Discharge Script

14. Case Study 2 …6 months later, Presentation to ED • Community acquired pneumonia complicated by her past medical history • Blood glucose levels unstable • Minor dehydration • Impaired renal function

15. Case Study 2: Tasks TASK 1: Find and review Resus Plan in Chart provided. Identify key elements to consider TASK 2: Write up Insulin Order TASK 3: Complete a Death Certificate

16. Orientation: Debrief • Audit Results • Clinical Coding • Feedback from Interns

17. End of Term Audit & Reports

18. End of Term Interviews End of Term Interview process

19. Mid Year Group Results

20. End of Year Analysis Annual Report • Group results • Comparison with overall hospital documentation results Awards • Best overall result

21. Intern’s Perspective

22. Lessons Learnt Lessons Learnt

23. Where to from here?