Documentation Workgroup: Progress Report

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Presentation transcript:

Documentation Workgroup: Progress Report Hospital Medicine Retreat May 25, 2016

Documentation Work-Group Dana Davis (Chair) Perryman Collins (UNMH) Diedre Hofinger (VA) David Olson (VA) Rush Pierce (UNMH) Susan Showers (SRMC) Libby Peters (Administrative support)

Problem Statement Current documentation in the hospital by attendings, advanced practice providers, and residents is sub optimal for purposes of provision of patient care, billing and coding, and utilization review.

Near-term goal/meetings Standardize consistency and improve quality of information provided in Discharge Summaries Meetings to date: 10/14/15 (Fall retreat) 11/05/16 03/17/16 05/10/16

What has been accomplished Review of the literature on elements of a good discharge summary. Review the VA template for discharge summaries Surveyed UNM PCP’s Agree on D/C Summary Essentials Elements Education of UNM Hospitalists/Residents Retrospective review of D/C Summary compliance with Essential Elements

PCP Survey Design: 95 responses (54% response rate) 8 item survey sent to UNM Primary Care Providers in February 98 Family Medicine and 79 Internal Medicine Included residents 95 responses (54% response rate)

Q1: What is your department?

Q2: What is your provider type?

39% (also 35% no preference) Strongly agree/agree Discharge summaries from UNMH are very useful to me in providing follow-up care to my clinic patients. 83% Discharge summaries from UNMH are very consistent in the way the information is organized. 36% Discharge summaries from UNMH are very consistent in types of information presented. 41% I prefer discharge summaries in dynamic documentation format 39% (also 35% no preference)

What is the usefulness of these components? Date admission/discharge Discharging attending physician Discharging resident Discharging team color Final diagnoses Brief description of reason for admission List of operations and procedures Significant finding and test results Brief hospital course Condition of patient on discharge Medication list on discharge Follow-up appointments Anticipated problems and suggested interventions Pending laboratory work and tests Code status during hospitalization

Essential/very useful > 80% Date of admission and discharge Final diagnoses Brief description of reason for admission Brief hospital course Condition of patient on discharge List of operations and procedures Other significant findings and test results Medication list on discharge Follow-up appointments Anticipated problems and suggested interventions Pending laboratory work and test

UNMH Discharge Summary Audit: Summaries from 01/16

UNMH Discharge Summary Audit: other problems Xray results under operations & procedures Problem list and/or admitting diagnoses in addition to discharge diagnoses is confusing Discharge day exam not listed as such, not specific, inclusion of I/O Much cut and paste of irrelevant info, recs already completed, detailed x-ray results Poor organization, different fonts, sloppy appearance

Next Steps Additional education of residents/faculty Posting D/C Summary Essentials Elements in work stations Distribution of cards to residents/faculty Integration with VA Future audits for compliance Defining quality of information contained within D/C Summary Essentials Elements