Documentation our journey to the ehr so far
Download
1 / 35

Documentation: Our Journey to the EHR (so far!) - PowerPoint PPT Presentation


  • 140 Views
  • Uploaded on

Documentation: Our Journey to the EHR (so far!). Laura Triplett, Director, HIM Roseann Kilby, Clinical Informatics Analyst Becky Crane, Clinical Risk Manager. 367 Bed Community Health System in Quincy, Illinois 2,000 Employees 240+ Physicians Affiliates include:

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Documentation: Our Journey to the EHR (so far!)' - teague


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Documentation our journey to the ehr so far l.jpg
Documentation: Our Journey to the EHR (so far!)

Laura Triplett, Director, HIM

Roseann Kilby, Clinical Informatics Analyst

Becky Crane, Clinical Risk Manager


Slide2 l.jpg

367 Bed Community Health System in Quincy, Illinois

2,000 Employees

240+ Physicians

Affiliates include:

- Illini Community Hospital (Critical Access Hospital in Pittsfield)

- Community Outreach Clinic

- Denman Medical Equipment

- Denman Biomedical

- Quincy Health Care Management

- Blessing Physician Services

Schools of Nursing, Radiology and Laboratory


Our emr l.jpg
Our EMR…

  • Blessing Hospital implemented Sunrise Clinical Manager in February of 2006

    • Blessing Automated Record, or “BAR”

  • Illini Community Hospital implemented Sunrise Clinical Manager in August of 2010 (ER documentation in 2008)

    • “Mini-BAR”

  • Steering committee utilized to select vendor

  • Committee was multi-disciplinary


Migration strategy l.jpg
Migration Strategy

  • Orders, Results, Medication Administration Record, Nursing Worklists

  • Interdisciplinary Documentation & Dictated Documents

  • CPOE

  • Imaging System

    Legal Medical Record Policy – Maintains the timing of implementations


Interdisciplinary documentation l.jpg
Interdisciplinary Documentation

  • Policy and Procedure: requirements for electronic documentation is the same as paper documentation.

  • Need policy for downtime procedures

  • Electronic documentation enters date/time documentation occurs and by whom.

    • “Real time” documentation is highly encouraged

    • Date/time columns are created by staff that designate the date/time the event occurred

  • “WDL” - Within Defined limits-these items are defined per observation



Clinical alerts l.jpg
Clinical Alerts

  • Documents

    • Soft Stop: Blue exclamation mark ! - indicates this observation is mandatory for the document to be considered complete.

      • Reminds staff upon saving that these observations are necessary for completion, allows staff to save as incomplete

    • Hard Stop: Red asterisk *- indicates this observation is mandatory for the document to be saved. Staff must complete the observation to save the document.

    • All CAPS - indicates this observation is mandatory for the document to be considered complete.


Interdisciplinary documentation8 l.jpg
Interdisciplinary Documentation

  • Partnership with Clinical Practice Model Resource Center (CPMRC)

    • Knowledge Based Charting (KBC)-This included flow sheets and evidenced-based guidelines for the plan of care.

      • Enter the appropriate guideline to the plan of care-this pulls in appropriate interventions, patient education, and outcomes to the appropriate flowsheet


Clinical alerts9 l.jpg
Clinical Alerts

  • Flow sheets

    • Mandatory field is based upon completion of an observation

      Example: documentation of pulse oximetry requires the observation for documentation for patient requirements of oxygen


Copy forward auto enter l.jpg
Copy Forward/Auto Enter

  • Documents have the capability to copy forward information from previous documents.

  • Flow sheets have the capability to auto enter information from previous documentation on that flowsheet.

  • Staff are instructed that this is just a tool, that the information has to be verified with the patient that the information remains current.

  • Restrict what observations are allowed to copy forward/auto enter.


Copy forward physician documentation l.jpg
Copy Forward – Physician Documentation

Example…..

  • History and Physicals done within 30 days of admission

    • Ability exists to copy forward

  • Copying electronically makes it difficult to determine when the original was created

  • Recommend adding statement to copied forward document indicating that it isn’t an original

    "This document was copied forward from H&P, dated XXXX, visit XXXX. Please see additional update for this visit, XXXX, by Dr. XXXX, the attending of record."


Reports l.jpg
Reports

  • Test and Validate – our strategy

    • Create Report

    • Test using a fake patient

    • Copy production environment

    • Test report with real patient data

    • After validation, move to production environment

      What you document in the system may not look the same when printed


Downtime processes l.jpg
Downtime Processes

  • Locally stored on downtime PC’s every 15 min.

  • Hard copies of downtime forms

  • Backload documentation

    • Medications

    • Orders

    • Tasks

  • Depending on duration of downtime


Bar change control policy l.jpg
BAR Change Control Policy

  • Requests for new or revised changes

    • CIS Change Request Form

  • Requests for changes to MLM’s* or reports

    • MLM Request Form or Report Request Form

  • Forwarded to care delivery redesign

  • Changes made monthly unless emergent

    • *Medical Logic Model


Documentation l.jpg
Documentation

  • Legal record of care delivered

  • Communication mechanism between HCP’s of IDT

  • Goal: interdisciplinary, patient-focused, non-duplicative, individualized, concise and meaningful

  • Clinical Practice Guidelines used as part of POC

  • Interdisciplinary Education Record

  • Point of Care / Concurrent Charting


Frequency of charting l.jpg
Frequency of Charting

  • Systems Assessment by RN on Assessment/Interven-tion flowsheet every 24h

    • Daily between hours of 7am-3pm

  • Focused Assessment / Reassessment by RN

    • Between hours of 3pm-7am and as warranted by a change in condition

  • Change in condition, response to care, & transfers in level of care are documented throughout the day

  • Outcome statement completed each shift by RN

  • Each episode of teaching & pt/family response on Education Outcome Record by IDT

  • Additional flowsheets used as needed


Examples of flowsheets l.jpg
Examples of Flowsheets

  • Behavior/suicide

  • CAPD Exchange Record

  • CIWA

  • Diabetes/Glucometer

  • Mental Status Assessment

  • Neuro Assessment

  • NIH Stroke Scale

  • Nutritional Care Priority

  • Patient Controlled Analgesia

  • Respiratory Therapy

  • Restraint

  • Roto-Rest Bed


Pros cons of ehr l.jpg
Pros & Cons of EHR

  • Legible

  • Concise

  • Content guided by design to meet legal requirements; much like the “T-sheets” in the ED

  • Lose the story-telling aspect; fragmented

  • Printed version doesn’t look like electronic version

    • Check for accuracy


How to tell the story l.jpg
How to “Tell the Story”

  • Outcome – Evaluation document

  • 14. Adult Guideline Assess/Outcome Eval [7-Jul-2011 01:37], Visit: 1188, Nurse, Nancy (RN) [Signed: 7-Jul-2011 04:34] , Complete, Entered, Signed in Full, General

    Summary Statement : Alert/oriented. Wearing bi-pap at night and ET CO2 monitor. At times respirations were down to 9, held dilaudid until in teens. States is having urinary hesitency and feeling as if he is not empying bladder. Did bladder scan which showed no residual. Wife in room all night with him. C/O pain 5/10 to bilateral arms and back @ worst, 2/10 following dilaudid. No other complications.




Slide23 l.jpg


Slide24 l.jpg

In the first column, the nurse manually typed in “L” and “FiO2”.  In the second column, the nurse did not. When printed out, only the numbers appear – see next slide


Printed flowsheet what do the numbers indicate l.jpg
Printed flowsheet. What do the numbers indicate? “FiO2”.  In the second column, the nurse did not. When printed out, only the numbers appear – see next slide


Documentation faux pas l.jpg
Documentation faux pas “FiO2”.  In the second column, the nurse did not. When printed out, only the numbers appear – see next slide

  • Words like “Accidentally” or “Somehow”

  • Unit / staffing issues

    • Request for 1:1

  • What wasn’t done or Ordered

    • Fetal heart tones not assessed this shift

  • Criticizing Care of Others

    • Cooling blanket improperly applied by previous shift

  • Criticizing the Patient

    • “Patient is obviously not in as much pain as she says she is.”

  • Mention of Incident Report

    • “Notified risk management, and occurrence report completed.”


Metadata l.jpg
Metadata “FiO2”.  In the second column, the nurse did not. When printed out, only the numbers appear – see next slide

  • Data about data

  • Hidden attributes for individual file including name, dates, alterations, deletion, who accessed & from where

  • Includes e-mail information: header, blind carbon copy recipients, etc.


Litigation threat of litigation legal action or investigation l.jpg
Litigation, Threat of Litigation, Legal Action or Investigation

  • Remove chart from normal use to preserve in original state

  • Capture electronic data ASAP

  • Suspend routine destruction or disposition of records

  • Preserve all relevant records regardless of form


Slide29 l.jpg

  • Importance in a lawsuit cannot be over-emphasized Investigation

  • If factual, consistent, timely & complete - our best DEFENSE

  • “If it isn’t documented, it wasn’t done.”

  • Document observations, action, treatment and outcome of care YOU provided

    A plaintiff’s attorney has 2 years* to thoroughly

    review the chart for errors and omissions.


Slide30 l.jpg
WDL? Investigation


Slide31 l.jpg


Timely documentation l.jpg
Timely Documentation administered by nursing/signed off as 1500 grams of Vancomycin…

  • Failing to document real time could result in suspicion

    • E.g.: Documentation that occurred hours after pt death


Paint a clear picture l.jpg
Paint A Clear Picture administered by nursing/signed off as 1500 grams of Vancomycin…

  • Example: midnight documentation

    • “pt stable, vs good, plan discharge tomorrow.”

    • 3:30 am documentation of pt death.


Requests for records l.jpg
Requests for records administered by nursing/signed off as 1500 grams of Vancomycin…

  • Volume

    • Admission paperwork 23 pages in EHR

    • One day documentation – random – 46 pages

    • Largest request for records 8000+ pages ($2,500)

  • Disc Format used more & more


In summary l.jpg
In Summary administered by nursing/signed off as 1500 grams of Vancomycin…

  • Blessing’s Journey to the EMR

  • A few Lessons Learned

  • Some Do’s & Don’ts

  • Any suggestions, comments or questions?