Measurement for Medical Records: A Comprehensive Guide

1. Measurement for MedRec – Submitting DataJune, 2007 Virginia Flintoft, RN MSc Project Manager, SHN! Central Measurement Team

2. Measurement for Med Rec Objectives • Who and what to measure • Patient population for Med Rec • Sample size for QI • Finding your way around data recording • SHN Med Rec Data Collection Worksheets • Now what do I do with it? • Submitting the Measurement Worksheets • Then what happens?

3. Measurement for Med Rec Who and what to measure ●●● Patient population for Med Rec and sample size for QI

4. Selecting Patient Population • Patient Population – • Start at Admission • Identify large volume target group based on your patient demographics – for example… • over 65 years old … or … paediatrics • 5 or more meds • nephrology … or … CHF • Plan ahead for spread • over 65 years old or paediatrics • Remember to capture the plan in your charter

5. Recommended Sample Size • Baseline – • Acute Care - 10 – 20 patients per month • Large centres do 3 months of data collection • Long-term Care – based on admission volume • If average admission rate = >2/week – baseline sample same as Acute Care • If average admission rate = 1-2/week – do 2 months of admissions for baseline • If average admission rate = 2/month – do last 5-10 admissions for baseline

6. Recommended Sample Size • Monthly – • Acute Care - 10 – 20 patients per month • Avoid over-burdening staff with measurement • Long-term Care – based on admission volume • If average admission rate = >2/week – up to 10 / month • If average admission rate = 1-2/week – up to 10 / month • If average admission rate = 2/month – do all admissions • If average admission rate = 1/month or less – do every patient – use SHN tools – but recognize the difficulty of maintaining expertise with small samples - report quarterly