Documentation

1. Documentation Courtney Hebert, MD, MS Angela Wilson-VanMeter, RN, MS

2. Learning objectives • Differentiate between free-text entries and discrete data entry • Explain the advantage of discrete data entry in the context of clinical decision support capabilities, and re-use of data • Explain the advantage of free-text entries in the context of patient care • Describe the role of templates and justify their appropriate use • Identify poor documentation practices including copy-and-paste and failure to update templates • Identify high-risk documentation errors and evaluate methods for avoiding and correcting these • Evaluate the ability of the electronic health record to improve documentation and assess challenges with electronic documentation • Illustrate the importance of accurate and timely documentation • Compare provider and patient-generated health data

3. Types of documentation • Discrete data: Each data element is entered into its own field. Only allow certain data types (e.g., numerical, text from drop down). • Examples: laboratory tests, vital signs, ordered medications, diagnoses codes • Free text data: Unstructured narrative data • Examples: progress notes, radiology reports, comments in laboratory data

4. Comparison Discrete data Free text Can communicate more complex decision making Often easier to input compared to discrete data More flexible (i.e. don’t have to choose from a list of options or stay within acceptable ranges) Need advanced analytic techniques to use these data for research or quality improvement • Can trend values (e.g. temperature curve) • Can use controlled terminologies (e.g. ICD-10) and standards to help with secondary use and interoperability • Can use data to trigger clinical decision support • Can check for data quality when entering data

5. Activity 1 overview • Sign in • Open patient’s chart • Access flowsheet activity • Enter vital signs and comment • Graph vital signs • Enter problem

6. Activity 1 sign-in Sign in to Learn: Use your attending sign on: Username: name##att Password: your password set at my.osu.edu Enter PCTE INP as the department

7. Activity 1: open chart • Double click to open patient’s chart • You should have been assigned a patient named Ann Bagel with a unique middle initial • InSearch all admitted box (top right of patient list activity) type patient’s name (last name, first name, middle initials). Hit enter. • Your patient’s record should display • Find your patient’s name and double click on their record to open the hospital chart

8. Activity 1: access flowsheet activity • Click on the Flowsheets activity tab on the top of the screen. If you do not see the Flowsheets tab click on the carat on the right most tab • Click on the Vitals simple tab across the top. You may need to use the right arrow button to scroll to the right to find this tab.

9. Activity 1: enter vital signs • Type 100.4in the temp cell in the available column. Hit enter and you will see the cursor drops down to the next cell in the column • Click on the pulse cell, click on the pulse fieldand type 150 • Click on the piece of paper icon and type “the patient had just returned from walking with PT” Note! This comment is free text. It is useful because it may help explain the heart rate to some extent and could not be captured in an available discrete field. • Click Accept • Click the BP cell and type 100 and press enter Note! This gives you an error because it is not the correct format • Type 100/60 instead. Press enter • Click File in the left corner of the flowsheet section

10. Activity 1: graph vitals • Click on the carat next to the Graph button at the top • Click on vitals complex • The graph opens and you can trend all vital signs

11. Activity 1: enter problem Next you will enter a problem on the ‘problem list’ • Click on Problem list activitytab across the top • Click Add • Type Diabetes (IHIS gives you a list of possible choices, along with their ICD-9 and ICD-10 codes) • Choose the first option • For the Diabetes mellitus type, click on Type 2, for the Diabetes mellitus complications, click with unspecified complications and click accept and then click accept again. • You are finished with this activity. You may Close the patient workspace by clicking the x on the tab next to the patient’s name and log out or stay logged in for the next activity

12. Activity 1: conclusion • Sign in • Open patient’s chart • Access flowsheet activity • Enter vital signs and comment • Graph vital signs • Enter problem

13. Templates and Documentation short-cuts • Most EMRs give the opportunity to use templates to help with note writing • Templates can include standard text that is used in specialty-specific notes • Templates can “pull in” recent data (e.g., recent labs, vital signs) so the provider does not need to type these in • Danger! Templates need to be fully updated for each patient. The full note needs to be reviewed. • Danger! Copy-and-pasting notes may lead to errors in documentation if not updated fully

14. Activity 2: overview • Open patient’s chart • Open a note • Write a note by pulling in a smartphrase: .progress

15. Activity 2: open chart • You should still be logged in. • If you logged out, sign back in to IHIS Learn with your attending sign-on • Username: name##att • Password: your password set at my.osu.edu • Access the patient you were using for the previous activity • In Search all admitted box (top right of patient list activity), type your patient’s name (last name, first name, middle initials). Hit enter. • Your patient’s record should display • Find your patient’s name and double click on their record

16. Activity 2: open a note • Click on the Notes activity across the top • Click on new note at the top • In the type field, click on the magnifying glass and select progress notes

17. Activity 2: write a note • Click in the note field and type .progress and hit enter Note! You have just used a system smartphrase that will pull in some data for you automatically. You will see some fields have auto-populated, for example: recent medications, and vital signs. You will also see several areas with 3 asterisks *** (a.k.a., wildcards). These are to remind you to fill in these important parts of the note. • Under subjective highlight *** and type: • still having fevers and chills, no cough. • To get to the next *** hit F2. • Under physical exam, type • CV: RRR, no murmurs • Lungs: clear to auscultation bilaterally • Hit the F2 button again and type: • plan to start vancomycin 2g IV q12 hrs • Click on under Labs and type .lastCBCand hit enter, this should pull in the most recent complete blood count • Review your note and click sign. Stay logged in.

18. Activity 2: conclusion • Open patient’s chart • Open a note • Write a note by pulling in a smartphrase: .progress

19. High risk documentation practices • Copy + pasting notes • May not update the full note each time • Can pull forward erroneous data • Documenting in the wrong chart (copy and paste from one chart to another) • Documenting important medical information only in free-text (e.g. allergies, diagnoses)

20. Avoiding documentation errors • Avoid copy and paste • Always update all note fields • Verify identity of patient • Picture in chart • Barcode scan for medication administration • Document using the correct type of data entry (discrete/free-text) • Keep medical information up-to-date (clean up problem list)

21. Activity 3: overview • Access problem list activity • Resolve a problem • Update similar problem

22. Activity 3: access problem list • Using the same patient double click to open the patient’s chart • Click on Problem list activity tab across the top • Read through the problem list • Is there a problem that you think should be resolved?

23. Activity 3: resolve a problem • Click on acute cystitis • Note! Acute cystitis was entered as a problem in the distant past. This is an acute problem that is no longer active for the patient. • Click resolve

24. Activity 3: update a problem We’ve learned more about the patient’s diabetes and want to update the problem list: • Click on add, type Diabetes • For the type, click on type 2, for the complications, click with kidney complications, click with nephropathy. For long term insulin use, click with long term use. • Click accept Note! You get a pop-up asking if you would like to update a similar problem or to add a new problem. • To avoid a duplicate entry, click update similar problem • You are now finished with this activity. Click on the downward carat next to the Logout button in the top right of the screen and click Secure.

25. Activity 3: Conclusion • Access problem list activity • Resolve a problem • Update similar problem

26. Benefits/challenges of electronic documentation Benefits Challenges Practices like copy/paste can lead to overly long, complex notes that are difficult to read Documentation can take longer using EMRs than with paper No one has “ownership” of the chart so data may not be updated appropriately (e.g. problem list) The massive number of accumulated notes make it difficult to do a thorough chart review on complex patients • Can ensure that data are entered correctly (data quality checks – ranges for vitals, standard dosing for medications) • Can trend data over time easily • Allows multiple providers to see records from any location • Allows for secondary use of records for quality improvement/research • Some EHRs allow the user to use a search function

27. Patient generated health data • “Health related data created, recorded or gathered by or from patients (or family members or other caregivers) to help address a health concern” (healthit.gov) • Sources: • Surveys • Wearable devices (health trackers) • Home monitoring devices (blood pressure monitors) • Health history

28. Patient generated health data Benefits Challenges Who is responsible for monitoring these data? What should be included in the patient record? How to verify data quality? How to deal with large amounts of data? • Provide a more comprehensive picture of the patients health • Longitudinal data rather than a point in time (e.g., office visit) • Novel types of data (from wearable devices) may help better understand certain diseases

29. Case study • 45 y/o F presents to the ED with 5 days of cough and fever and is diagnosed with pneumonia • Resident sees patient and interviews her • Patient reports severe allergy to cephalexin (hives) • Resident documents this in his note 45 yo F with 5 days of cough an fever presenting with SOB. Reports severe allergy to cephalexin, specifically hives and swelling which occurred last year. Exam with crackles at left base Will get CXR.

30. Case Study • Resident signs his note at home after he finishes his shift. • Before the note is signed the next resident comes on, looks at the at the CXR which shows a LLL pneumonia and orders IV ceftriaxone. • Ceftriaxone is administered. • Patient develops hives and wheezing and requires epinephrine • A new antibiotic is ordered but the patient is admitted for observation given the severe allergic reaction.

31. What should have happened? • 45 y/o F presents to the ED with pneumonia • Resident sees patient and interviews her • Patient reports a severe allergy to cephalexin • Resident documents this in the allergies section of the chart immediately • The next resident orders IV ceftriaxone. • A warning comes up that the patient is allergic to a similar antibiotic. The resident orders moxifloxacin instead • The patient’s symptoms improve and she’s discharged from the emergency department on oral moxifloxacin

32. Activity 4: overview • Log in as a nurse • Apply a Care Plan • Document Goals • Create a Care Plan Note • Document interventions • Resolve problems • Assess patient’s learning readiness • Document patient education

33. Activity 4: Log in • Log in with your nurse login • This would be your med center id with the letters “RN” following it and then your regular med center password.

34. Activity 4: Apply care plan • Click on Care Plan activity on the tab across the top Note! Templates added should relate to the diagnosis or the top priority needs that are preventing the patient from getting to the next level of wellness. For additional help, select templates and click on the CPM button on the toolbar to review CPG’s that exist for your patient based on diagnosis, specialty, or target populations. Note! Care plans consists of Problem, Goal and Interventions: The Problem is identified by the “bandaid” looking icon The Green dot on the left under the problem is the Goal, and the Interventions specific to the problem is identified with a blue square Note! Expected End Dates for Goals are required to personalize the goal for your patient. In clinical practice, you may choose to enter a date related to the Expected Discharge date or one that would be appropriate to meet the goal. For this activity, we will enter a goal completion date within 4 days. • In the Goal Expected End Dates window, enter t+4 in the date field and click Accept

35. Activity 4: Goal documentation • From the Care Plan toolbar, select Document • SelectCare Plan Documentation tab in order to document on any or all Goals and Interventions • To the right of “Signs and Symptoms of Listed Potential Problems Will be Absent, Minimized or Managed (Diabetes, Type 2)” select “Progressing Toward Goal” speed button • Select Problem Interventions

36. Activity 4: Interventions • Interventions can be used to individualize the patients care plan. Interventions selected when initiating a care plan should be specific to the patient’s needs, and can be documented in the care plan or in the flowsheets in the intervention rows. Information from the flowsheets and care plan can be seen in both places. • ClickProblem Interventions • ClickSupport/Optimize Psychosocial Response to Condition • Under “Supportive Measures”, select problem solving facilitated and self care encouraged • Under “Family/Support System Care” select care giver stress acknowledged • Under “Environmental Support” Select calm environment promoted and care giver consistency promoted • Scrolldownand select Optimize Glycemic Control, which opens the next intervention for this problem • Under “Glycemic Management”, Select blood glucose monitoring • Click Next

37. Activity 4: Create care plan note • Now, we will document a Care Plan Note using the information we’ve already documented on flowsheet rows associated with the goal. • Under Progressing Toward Goal, select +Add next to “Signs and Symptoms of Listed Potential Problems will be absent, minimized or managed (Diabetes, Type 2) • Under No Outcome, select+Add next to Support/Optimize Psychosocial Response to Condition” • SelectSignin the lower right hand corner to sign your note. Note! This action has resulted in the creation of a care plan note. This note can be found in the care plan activity under Care Plan Progress Notes, in chart review under notes tab- filter on plan of care; the note can also be found under the Summary report activity> care plan/pt ed.

38. Activity 4: Resolving Problem • Diabetes Type 2 Adult • Care plans need to be revised based on the assessment and needs of the patient. • Highlight the problem (remember it looks like the bandaid icon) and click theResolve button under the Diabetes, Type 2 (Adult) window on the right. The Resolve Problem form opens. • To resolve a problem for a patient, click the check box located beside the name of the problem you need to resolve and select an outcome for the problem by clicking the down arrow for a selection list. For this activity we will selectCompleted and click Accept to save your changes.

39. Activity 4: Assess learner readiness Assessing the learner prior to initiating patient education is necessary in order to provide the appropriate education material based on patient preferences. Let’s assess our patient: Click Education tab across the top (next to the Care Plan tab) Select the Assessments tab and click +Create New Complete Learning Assessment Form: • Unable to assess: NA • Primary learner’s name:Leave blank • Relationship; Patient • Does the primary learner have any barriers to learning? No barriers • Describe the primary learner’s learning barrier: Free text anything you’d like • What is the primary language of the primary learner? English • Preference for primary learner’s written language? English • Is an interpreter required? No • How does the primary learner prefer to learn? Listening, Reading, Picture/Videos • Do you often need help from someone when reading or filling out medical forms? no Scroll down to address any special topics and • Answered by: Learning assessment questions answered by? Leave blank • Relationship: patient Note! As you see there is an opportunity to assess the learning readiness of up to 2 co-learners. • After completing the learning assessment select File. • Select the Education tab

40. Activity 4: Document education Select and document education points that you want to teach on. • For this activity, we will select Physiology under Diabetes Type 2 Overview topic • In the lower right hand corner select Document • A learner readiness pop up box will appear with check boxes for Learner, Readiness, Method and Response • Select Learners: patient, Readiness: eager, Method: handout reviewed and explanation, Response: states/identifies/teaches back • Select File Note! A response of No learning, Needs review, or Partially complete marks the point as started but not completed and is designated with a yellow rotation symbol. A green checkmark denotes the education is complete. To keep the Education tab as cleaned up as possible and to minimize scrolling to get to the teaching points still to be addressed, you should resolve teaching titles where all points in a title are completed. Education needs to be resolved prior to discharge if education is complete

41. Activity 4: Conclusion • Apply a Care Plan • Document Goals • Create a Care Plan Note • Document interventions • Resolve problems • Assess patient’s learning readiness • Document patient education

42. Summary • Discrete data and free-text data entry have unique benefits and downsides and should be used appropriately • Documentation errors and high-risk documentation practices can lead to poor patient care • EMRs can help to prevent some documentation errors, but providers must be aware of electronic documentation high-risk practices and do their best to keep charts accurate and up to date

43. Thank you Thank you for reviewing the module within IHIS Learn. After completing any exercises associated with this module within the IHIS Learn environment, please return to Carmen to complete the required end-of-module survey before the deadline specified in Carmen. Through this survey you will provide feedback about your experience with the learning module and answer some questions to gauge your knowledge after completing the module