Presentation on theme: "Documentation: Our Journey to the EHR (so far!)"— Presentation transcript:
1Documentation: Our Journey to the EHR (so far!) Laura Triplett, Director, HIMRoseann Kilby, Clinical Informatics AnalystBecky Crane, Clinical Risk Manager
2367 Bed Community Health System in Quincy, Illinois 2,000 Employees240+ PhysiciansAffiliates include:- Illini Community Hospital (Critical Access Hospital in Pittsfield)- Community Outreach Clinic- Denman Medical Equipment- Denman Biomedical- Quincy Health Care Management- Blessing Physician ServicesSchools of Nursing, Radiology and Laboratory
3Our EMR…Blessing Hospital implemented Sunrise Clinical Manager in February of 2006Blessing Automated Record, or “BAR”Illini Community Hospital implemented Sunrise Clinical Manager in August of 2010 (ER documentation in 2008)“Mini-BAR”Steering committee utilized to select vendorCommittee was multi-disciplinary
4Legal Medical Record Policy – Maintains the timing of implementations Migration StrategyOrders, Results, Medication Administration Record, Nursing WorklistsInterdisciplinary Documentation & Dictated DocumentsCPOEImaging SystemLegal Medical Record Policy – Maintains the timing of implementations
5Interdisciplinary Documentation Policy and Procedure: requirements for electronic documentation is the same as paper documentation.Need policy for downtime proceduresElectronic documentation enters date/time documentation occurs and by whom.“Real time” documentation is highly encouragedDate/time columns are created by staff that designate the date/time the event occurred“WDL” - Within Defined limits-these items are defined per observation
7Clinical AlertsDocumentsSoft Stop: Blue exclamation mark ! - indicates this observation is mandatory for the document to be considered complete.Reminds staff upon saving that these observations are necessary for completion, allows staff to save as incompleteHard Stop: Red asterisk * - indicates this observation is mandatory for the document to be saved. Staff must complete the observation to save the document.All CAPS - indicates this observation is mandatory for the document to be considered complete.
8Interdisciplinary Documentation Partnership with Clinical Practice Model Resource Center (CPMRC)Knowledge Based Charting (KBC)-This included flow sheets and evidenced-based guidelines for the plan of care.Enter the appropriate guideline to the plan of care-this pulls in appropriate interventions, patient education, and outcomes to the appropriate flowsheet
9Clinical Alerts Flow sheets Mandatory field is based upon completion of an observationExample: documentation of pulse oximetry requires the observation for documentation for patient requirements of oxygen
10Copy Forward/Auto Enter Documents have the capability to copy forward information from previous documents.Flow sheets have the capability to auto enter information from previous documentation on that flowsheet.Staff are instructed that this is just a tool, that the information has to be verified with the patient that the information remains current.Restrict what observations are allowed to copy forward/auto enter.
12Copy Forward – Physician Documentation Example…..History and Physicals done within 30 days of admissionAbility exists to copy forwardCopying electronically makes it difficult to determine when the original was createdRecommend adding statement to copied forward document indicating that it isn’t an original"This document was copied forward from H&P, dated XXXX, visit XXXX. Please see additional update for this visit, XXXX, by Dr. XXXX, the attending of record."
13What you document in the system may not look the same when printed ReportsTest and Validate – our strategyCreate ReportTest using a fake patientCopy production environmentTest report with real patient dataAfter validation, move to production environmentWhat you document in the system may not look the same when printed
14Downtime Processes Locally stored on downtime PC’s every 15 min. Hard copies of downtime formsBackload documentationMedicationsOrdersTasksDepending on duration of downtime
15BAR Change Control Policy Requests for new or revised changesCIS Change Request FormRequests for changes to MLM’s* or reportsMLM Request Form or Report Request FormForwarded to care delivery redesignChanges made monthly unless emergent*Medical Logic Model
16Documentation Legal record of care delivered Communication mechanism between HCP’s of IDTGoal: interdisciplinary, patient-focused, non-duplicative, individualized, concise and meaningfulClinical Practice Guidelines used as part of POCInterdisciplinary Education RecordPoint of Care / Concurrent Charting
17Frequency of ChartingSystems Assessment by RN on Assessment/Interven-tion flowsheet every 24hDaily between hours of 7am-3pmFocused Assessment / Reassessment by RNBetween hours of 3pm-7am and as warranted by a change in conditionChange in condition, response to care, & transfers in level of care are documented throughout the dayOutcome statement completed each shift by RNEach episode of teaching & pt/family response on Education Outcome Record by IDTAdditional flowsheets used as needed
18Examples of Flowsheets Behavior/suicideCAPD Exchange RecordCIWADiabetes/GlucometerMental Status AssessmentNeuro AssessmentNIH Stroke ScaleNutritional Care PriorityPatient Controlled AnalgesiaRespiratory TherapyRestraintRoto-Rest Bed
19Pros & Cons of EHR Legible Concise Content guided by design to meet legal requirements; much like the “T-sheets” in the EDLose the story-telling aspect; fragmentedPrinted version doesn’t look like electronic versionCheck for accuracy
20How to “Tell the Story” Outcome – Evaluation document 14. Adult Guideline Assess/Outcome Eval [7-Jul :37], Visit: 1188, Nurse, Nancy (RN) [Signed: 7-Jul :34] , Complete, Entered, Signed in Full, GeneralSummary Statement : Alert/oriented. Wearing bi-pap at night and ET CO2 monitor. At times respirations were down to 9, held dilaudid until in teens. States is having urinary hesitency and feeling as if he is not empying bladder. Did bladder scan which showed no residual. Wife in room all night with him. C/O pain 5/10 to bilateral arms and worst, 2/10 following dilaudid. No other complications.
22Item from pick list must be selected in order for header to be visible on printed report.
23In this example, the nurse manually typed in “intermittent” under grunting and “slight” under intercostal retraction.
24In the first column, the nurse manually typed in “L” and “FiO2” In the first column, the nurse manually typed in “L” and “FiO2”. In the second column, the nurse did not. When printed out, only the numbers appear – see next slide
25Printed flowsheet. What do the numbers indicate?
26Documentation faux pas Words like “Accidentally” or “Somehow”Unit / staffing issuesRequest for 1:1What wasn’t done or OrderedFetal heart tones not assessed this shiftCriticizing Care of OthersCooling blanket improperly applied by previous shiftCriticizing the Patient“Patient is obviously not in as much pain as she says she is.”Mention of Incident Report“Notified risk management, and occurrence report completed.”
27Metadata Data about data Hidden attributes for individual file including name, dates, alterations, deletion, who accessed & from whereIncludes information: header, blind carbon copy recipients, etc.
28Litigation, Threat of Litigation, Legal Action or Investigation Remove chart from normal use to preserve in original stateCapture electronic data ASAPSuspend routine destruction or disposition of recordsPreserve all relevant records regardless of form
29Importance in a lawsuit cannot be over-emphasized If factual, consistent, timely & complete - our best DEFENSE“If it isn’t documented, it wasn’t done.”Document observations, action, treatment and outcome of care YOU providedA plaintiff’s attorney has 2 years* to thoroughlyreview the chart for errors and omissions.
31Medication order was entered, verified by pharmacy and administered by nursing/signed off as 1500 grams of Vancomycin…Patient was charged $79,181.10
32Timely DocumentationFailing to document real time could result in suspicionE.g.: Documentation that occurred hours after pt death
33Paint A Clear Picture Example: midnight documentation “pt stable, vs good, plan discharge tomorrow.”3:30 am documentation of pt death.
34Requests for records Volume Disc Format used more & more Admission paperwork 23 pages in EHROne day documentation – random – 46 pagesLargest request for records pages ($2,500)Disc Format used more & more
35In Summary Blessing’s Journey to the EMR A few Lessons Learned Some Do’s & Don’tsAny suggestions, comments or questions?