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VANDERBILT HOME CARE SERVICES Quality Of Documentation Of Rehab Staff Over The Course Of Patient Treatment.

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Presentation on theme: "VANDERBILT HOME CARE SERVICES Quality Of Documentation Of Rehab Staff Over The Course Of Patient Treatment."— Presentation transcript:

1 VANDERBILT HOME CARE SERVICES Quality Of Documentation Of Rehab Staff Over The Course Of Patient Treatment

2 Purpose To determine which Key Function Indicators are most frequently missed during clinical documentation

3 Goal To improve rehab documentation of all staff from evaluation to discharge of patients in order to meet agency standard of 100% on Key Functions on CQI monitor

4 Procedure/Process/Methodology 1)Chart audits of Key Functions were performed from April, 2007, through June, )Data was organized by type of clinician (OT, PT, ST), by division (pediatrics, adult), and by whether the staff was salaried or pay-per-visit 3)Data results were reviewed with administrators 4)Current learning tool for documentation was reviewed and updated

5 Procedure/Process/Methodology 5) New staff was instructed in proper documentation needed to fulfill Key Functions on CQI monitor 6) Proposed – Distribute new learning tool to all staff and instruct in how to document properly for Key Functions on CQI monitor (This process was never completed due to CQI leaders agency position was eliminated prior to completion of CQI project)

6 Procedure/Process/Methodology 7)Proposed – Perform additional chart audits by March, 2009, to document improvement in staff documentation in order to meet agency standard of 100% on Key Functions of CQI monitor ((This process was never completed due to CQI leaders agency position was eliminated prior to completion of CQI project)

7 Assessment Therapists most frequently omitted items on Key Functions on CQI monitor: Patient/Caregiver understands and agrees to participate in Plan of Care (14 times) If pain is present, plan for management is established (8 times) Discharge planning is initiated on admission (5 times) Pain is assessed with every visit (4 times)

8 Assessment Percentage of charts completed properly by agency rehab disciplines (OT, PT, ST), comparing salaried and pay-per-visit: Agency (all disciplines) – 95.7% Agency (all salaried) % Agency (all pay-per-visit) – 94.5%

9 Assessment Percentage of charts completed properly by agency rehab staff, comparing disciplines (OT, PT, ST): Physical Therapy (salaried) % Physical Therapy (pay-per-visit) – 93.6% Occupational Therapy (pay-per-visit) – 97.5% Speech Therapy (pay-per-visit) – 92.5%

10 Assessment Percentage of charts completed properly by agency rehab staff, comparing pediatric and adult staff: Physical Therapy (adult) % Physical Therapy (peds) % Occupational Therapy (peds) – 97.5 Speech Therapy (adult) – 92.5%

11 Recommendations Finish updating documentation learning tool Distribute updated documentation learning tool to all staff and instruct in changes Using updated documentation learning tool, instruct each new staff on documentation needed in order to meet agency standard of 100% on Key Functions on CQI monitor After using updated documentation learning tool, complete 3 months of chart audits to measure the tools effectiveness


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