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

2. 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)

3. 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.

4. 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

5. 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

6. 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)

7. Q1: What is your department?

8. Q2: What is your provider type?

9. 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)

10. 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

11. 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

12. UNMH Discharge Summary Audit: Summaries from 01/16

13. 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

14. 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