Educational Sound Bites - Highland Chart Audit System H. Gene Hern, Jr., MD, MS, Charlotte Wills, MD, Barry Simon, MD Dept. of Emergency Medicine ACMC-Highland General Hospital, Oakland, CA

 RRC has mandated evaluation Chief Complaint Competencies Chief Complaint Competencies Year End Competencies Year End Competencies Six Core competencies Six Core competencies  Few few sources of evaluation Direct observation of the resident Direct observation of the resident Indirect evaluation of their charting Indirect evaluation of their charting Background

Objective  We intended to create a system which is: A reflection of the direct observation of the resident by their supervising attending A reflection of the direct observation of the resident by their supervising attending ANDAND An indirect measure of their Core and Chief Complaint competencies. An indirect measure of their Core and Chief Complaint competencies.

Methods  We created an online chart audit system to allow attending faculty to provide feedback on the resident’s patient care documentation To the resident To the resident To the program To the program

 Within our ED electronic record, there is a drop down link that is a quicklink to an online form.  The attending fills out the form which asks questions about the resident’s documentation of H&P, Procedure, MDM, DDX, and Plan.  It asks specific questions about clarity of PE and evidence the templated PE was modified or not used.  In addition it has space for comments about breadth of DDX and MDM and further comments. Methods

Methods  Once completed, copies of the evaluation are sent to The resident The resident The program and associate program director The program and associate program director The chairman of the department The chairman of the department  Attendings are required by the Chairman to do one chart eval per shift.

Results  We have implemented using our existing ED Information System: A reliable, safe, and relevant feedback system A reliable, safe, and relevant feedback system Allows immediate feedback to our residents on patients they have seen recently. Allows immediate feedback to our residents on patients they have seen recently. The chart evaluations go into their file and are referenced in their bi annual evaluations. The chart evaluations go into their file and are referenced in their bi annual evaluations.

 This system is ongoing, with unselected patients and involves all faculty and all patient acuities  It provides ample insight into the thoroughness of the resident’s documentation and attempts to match the documentation with the care provided.  This not only allows attendings to provide resident feedback on the chart but also allows them to provide feedback on the care and on the discharge plan for the cases they actually supervised Results

 The enforcement of the one shift – one chart evaluation system is done via the Department Chair  The percentage of chart evaluations completed figures into the Chair’s determination of faculty bonus at the end of the year  The feedback has been well received by the residents and generally accepted by the attendings. (Completion rate >70%) Results

75 Chart Audits Completed in 2/11

Conclusion  An online chart audit system  Allows real time feedback on actual patient encounters (all complaints)  Provides the attending with a representation of an actual patient encounter which they supervised.  It provides the resident with immediate feedback on their chart and is ed directly to them.  It allows greater evaluation of chief complaint as well as core competencies for ACGME and RRC accreditation.

Thanks  Questions??