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Physician Documentation: Success with a S.O.A.P. Note Meditech Regional User Conference September 17th, 2009

Physician Documentation: Success with a S.O.A.P. Note Meditech Regional User Conference September 17th, 2009. Prince William Hospital. 170 Bed Birthing Center Pediatrics Emergency Surgery Diagnostic Service Mental Health-Inpatient & Outpatient Cancer Program Home Health Rehabilitation.

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Physician Documentation: Success with a S.O.A.P. Note Meditech Regional User Conference September 17th, 2009

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  1. Physician Documentation:Success with a S.O.A.P. NoteMeditech Regional User ConferenceSeptember 17th, 2009

  2. Prince William Hospital • 170 Bed • Birthing Center • Pediatrics • Emergency • Surgery • Diagnostic Service • Mental Health-Inpatient & Outpatient • Cancer Program • Home Health • Rehabilitation

  3. Respiratory Care • Sleep Disorder Center • Assisted Living • Fitness Center • Marblestone Health Center • Surgery Center • Wellness Center • Healthcote Health Center • U.S. Senate Productivity & Quality Award Winner • Press Ganey Compass Award for Outpatient Services Patient Satisfaction • Merger with Novant Health

  4. Prince William Hospital • Admissions – 10,788 • ER Visits – 56,811 • Deliveries – 2,393 • Outpatient Visits – 145,764 • Gross Revenue – $386,500,000 • Charity Care – $10,700,000

  5. Our Road to an EHR

  6. Our Road to an EHR

  7. Agenda • Why & How? • Keys to Success • Organizational Benefits

  8. EMR Gap Analysis • What pieces of the chart are still on paper? • Physician Progress Notes – (most urgent) • Physician Orders • ER records • Anesthesia Records

  9. Challenges with Paper Progress Notes • Handwritten, difficult to read/interpret • Charts can be difficult to find • One chart to share among several clinicians • Case Management frustration in dealing with insurance companies as a result of documentation issues • Decreased revenue due to missing/incomplete documentation

  10. Why not traditional transcription?? • Discharge Summaries, History and Physicals, Consults, and Operative Summaries work well • Turn-around time is 4 hours • Clinicians need real time access to information for treatment plans and consulting with other physicians • Patient dissatisfaction with delay in treatment

  11. Why Meditech PDoc?? • Physician progress notes furthers the PWHS EHR which is an organizational goal • Templates may be customized to physician preferences • Electronic documentation is available in the EHR immediately in 2 locations, “Other Reports”, and “Notes” • The EHR offers both speed and efficiency in the documentation and improvement of patient data

  12. Progress Note Pilot Program • Began October 30, 2007 • Pediatric area of hospital (inpatient) • Small controlled environment • One on one training • Group of 20 docs • Low census area

  13. S O A P • Free Text box • Subjective Objective • Free Text box • Vitals/ I&O’s – last recorded • Physical Exam – dropdown lists • Medications (My Data) • Labs – resulted in last 24 hr • Free Text box • Recall Text Assessment • Plan • Free Text box • Recall Text

  14. Soap Note

  15. Subjective

  16. Objective

  17. Objective

  18. Objective

  19. Physical exam

  20. My Data

  21. Medication

  22. Labs

  23. Radiology

  24. Consults

  25. Assessment

  26. Plan

  27. Medical Necessity

  28. Keys to Success • Physician Leadership & Involvement • Director of Medical Informatics - .2 FTE in IT • Physician Advisory Group – PAG • EHR Warriors • Training and Support • 1:1 On Site at Go-Live • Morning, Noon and Night

  29. Keys to Success • Dedicated Meditech Help Line • 7 AM – 5:3 PM Monday – Friday • Remote Access to Desktop • They Know our Cell Phones !!! • Listen (they have great ideas) • Follow Through • Be Honest About What you CAN do and What you CANNOT do • Embrace the K.I.S.S Principle

  30. With Success Expect a few Bumps • Attitude Not Aptitude • Embrace the Skeptics—Manage the Disruptive • Circles of Influence--Peer pressure will eventually come into play • PATIENCE, PATIENCE, PATIENCE!!!!!

  31. Organization wide benefits • Increased physician satisfaction • Remote access—office, home, physician lounge • Improved information access  Enhanced patient care • Ability to Encourage “Safe” Documentation

  32. Expanding our horizons • 2008 • January – Cardiology, Pulmonary, Gastroenterology • March - Family Medicine, Internal Medicine • June – General Surgery, Nephrology, ENT • August – Oncology, Infectious Disease, Neurology • October – Allergy, Dermatology, Endocrinology, Interventional Radiology, Pain Management, Pediatric Cardiology • November – Orthopedics, Podiatry

  33. Expanding our horizons • 2009 - Present • February – Obstetrics, Gynecology, OB Hospitalists • April – Internal Medicine Hospitalists • May – Cancer Staging Form • Under Construction • Newborn • Template Design • Admission • Discharge • Consults

  34. Thank You Bonnie Seekford Clinical Analyst 703-369-8439 bseekfor@pwhs.org

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