1. Department of Medicine Performance Improvement Record Completion

2. Regulatory Background DOH, The Joint Commission and TUH MS Bylaws require record completion w/in 30 days of discharge. Any incomplete record > 30 days is considered Delinquent. TJC & DOH require monitoring and reporting of delinquent records.

3. DOM & MRD: Joint Efforts Early process developed w/ DOM Chief Dr. Karen Lin Ongoing weekly communication with Chief Residents regarding delinquent residents. MRD paging of delinquent residents. Chiefs direct communication with delinquent residents. Goal: decrease need for MIS suspension.

4. Technology Enhancements 1/07 Implementation of electronic record completion module in Alpha Imaging. Physician direct access to incomplete record lists via Alpha sign-on. e-Sign capability. Auto e-mail notification of outstanding records. “waiting for Dr… to dictate” upgrade.

5. Data Trending

6. Delinquent Record Detail ResidentAttending DateDictationsSignatures 1/11/2007161179 3/28/2007130156 6/27/200788152 10/31/20072692 1/30/20086241 4/28/20088422 7/31/20084338 10/31/20087344 1/30/20093644 4/17/20093744

7. DC Summary: Next Steps DC Summary simplification process for short stay cases (< 5 day LOS) Joint CHF Workgroup and Medical Record Committee Recommendation Address CHF CORE DC medication documentation requirements Developed with DOM Chief Residents

8. MIS DC Summary/DC Instruction MIS template document created & resident completes for discharge: DC instructions. DC Summary (<5 day LOS). Auto fax to PCP. Signed by attending physician and complete record without further dictation. DC summary dictation still required for LOS 5 day and greater. Anticipated transcription savings: $52 K per year --3 & 4 day LOS - 23% volume.