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Physician Documentation: Success with a S.O.A.P. Note Meditech Regional User Conference September 17th, 2009 PowerPoint Presentation
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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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slide1

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

slide2

Prince William Hospital

  • 170 Bed
  • Birthing Center
  • Pediatrics
  • Emergency
  • Surgery
  • Diagnostic Service
  • Mental Health-Inpatient & Outpatient
  • Cancer Program
  • Home Health
  • Rehabilitation
slide3

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
slide4

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
slide7

Agenda

  • Why & How?
  • Keys to Success
  • Organizational Benefits
slide8

EMR Gap Analysis

  • What pieces of the chart are still on paper?
    • Physician Progress Notes – (most urgent)
    • Physician Orders
    • ER records
    • Anesthesia Records
slide9

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
slide10

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
slide11

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
slide12

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
slide13

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
slide28

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
slide29

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
slide30

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!!!!!
slide31

Organization wide benefits

  • Increased physician satisfaction
    • Remote access—office, home, physician lounge
  • Improved information access  Enhanced patient care
  • Ability to Encourage “Safe” Documentation
slide32

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
slide33

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
slide34

Thank You

Bonnie Seekford

Clinical Analyst

703-369-8439

bseekfor@pwhs.org