Metro North Dispelling Bad Documentation Habits in Clinicians Early Michelle Leeding – Health Information Manager Debbie Tansacha – Medical Education Officer

Metro North Health Service District The Journey

Metro North Health Service District Setting the scene Background rationale Medical Education Unit Intern Program Lessons Learnt Where to from here? Overview

Metro North Health Service District Setting the Scene

Metro North Health Service District Setting the Scene

Metro North Health Service District Recommendation from Coroners Report Establishment of new HIMS position Improvement of Intern Orientation program Background Rationale

Metro North Health Service District Coroners Report Black, T,J Inquest into the cause and circumstances surrounding the death of Kenneth Maggable on 9 August 2005, Findings. Background Rationale

Metro North Health Service District Background Rationale Health Information Management Service Medical Education Unit Background Rationale

Metro North Health Service District Role: Coordinates the education and training of Resident Medical Officers (Intern to PHO) within Redcliffe Hospital in line with accreditation standards and medical registration regulations Medical Education Unit

Metro North Health Service District 1.Orientation / debrief 2.End of Term Audits 3.End of Term Reports / Statistics 4.End of Term Interview process 5.Mid year group results 6.End of year comparative analysis Intern Program: Phases

Metro North Health Service District Intern Program: Orientation

Metro North Health Service District Mabel Smith: 79yo female Admitted to Orthopaedic Ward Fractured Neck of Femur Initial pain relief in ED PMH: Ischaemic Heart Disease, Type II Diabetes SxH: Widowed, lives alone Allergy: Cephalexin Case Study 1

Metro North Health Service District TASK 1: Write up the admission progress notes in the chart provided TASK 2: Write up Medication Chart TASK 3: Complete Discharge Script Case Study 1: Tasks

Metro North Health Service District …6 months later, Presentation to ED Community acquired pneumonia complicated by her past medical history Blood glucose levels unstable Minor dehydration Impaired renal function Case Study 2

Metro North Health Service District TASK 1: Find and review Resus Plan in Chart provided. Identify key elements to consider TASK 2: Write up Insulin Order TASK 3: Complete a Death Certificate Case Study 2: Tasks

Metro North Health Service District Audit Results Clinical Coding Feedback from Interns Orientation: Debrief

Metro North Health Service District End of Term Audit & Reports

Metro North Health Service District End of Term Interview process End of Term Interviews

Metro North Health Service District Mid Year Group Results

Metro North Health Service District Annual Report Group results Comparison with overall hospital documentation results Awards Best overall result End of Year Analysis

Metro North Health Service District Interns Perspective

Metro North Health Service District Lessons Learnt

Metro North Health Service District Where to from here?