1 QUALITY OF DOCUMENTATION IN MEDICAL RECORDS NYCHSRO’s Experience in Title I Quality Management Review New York County Health Services Review Organization Harriet Starr Vice President, Government Contracts

2 ISSUES IN THE QUALITY OF MEDICAL RECORD DOCUMENTATION  Timely and accurate documentation is associated with: associated with:  improved quality of care  seamless continuity of care  enhanced ability to demonstrate equitable delivery of service and improved outcomes  streamlined work processes  reduction in the duplication of work  reliable data sources  increased client, worker and payer satisfaction

3 ISSUES IN THE QUALITY OF MEDICAL RECORD DOCUMENTATION  Problems with documentation are reflected in lower scores on quality indicators  Quality of care may appear worse than actual

4 NEW YORK COUNTY HEALTH SERVICES REVIEW ORGANIZATION (NYCHSRO)  Review agent for AIDS Institute Title I Quality Management Program since 2001  Reviewed the following programs:  Case Management  Treatment Adherence  Food and Nutrition  Home Care  TB DOT  currently reviewing Harm Reduction

5 NYCHSRO’s EXPERIENCE  Reviewed approximately  2700 records at 74 programs in 2005  2900 records at 44 programs in 2006  5600 in last 2 years

6 NYCHSRO’s EXPERIENCE (continued)  Observations about the quality of documentation in medical records  Based on reviewers’ impressions on completion of a facility’s reviews  Taken mainly from 2005 Food & Nutrition reviews (850 records at 14 providers) and 2006 Case Management review (2700 records at 31 providers)  Findings are representative of 1/3 to 1/2 of records at nearly half of the providers

7 OBSERVATIONS  Critical information not documented  Lists of community food and nutrition services provided at intake, automatically or on request, but not documented in client record  No documentation for months at a time. Was client disenrolled from program?

8 OBSERVATIONS  Documentation not dated  Dates of primary care physician visits, lab values (CD4 counts and Viral Loads), and lists of ARV medications missing  PCP appointments discussed in progress notes, but dates of appointments not documented  Photocopies of PCP appointment cards lacked year of service  Progress notes not dated

9 OBSERVATIONS  Disorganized record  Difficult to locate demographics and follow-up assessments, particularly of client weight and HIV medications  Progress notes not sequential  CD4 and Viral Load values found in different location than dates of these tests

10 OBSERVATIONS  Incomplete record; documentation stored in too many places  Dates of educational sessions stored in different location than topic  Intake information only kept in oldest of multiple charts

11 OBSERVATIONS  Incomplete record; documentation stored in too many places (continued)  Primary care data (HIV medications, PCP visits, CD4, viral load) stored only in charts from other programs (e.g., Case Management) and not in Food & Nutrition chart  Demographics only in URS, not in chart

12 OBSERVATIONS  Documentation is too general  Schedule of educational sessions provided; no topic available  Topic of educational session identified only as education

13 OBSERVATIONS  Documentation is too general (continued)  Client need identified as entitlement; no clarification as to whether need was for food stamps, ADAP, Medicaid, etc.  Unable to distinguish between client’s primary medical care and mental health visits

14 OBSERVATIONS  Documentation is illegible  Illegible handwriting in notes  Can’t identify provider; can’t read signature  Photocopies too light or smeared/distorted  3 rd or 4 th copy of multipart form; nothing legible

15 OBSERVATIONS  Inconsistencies among documentation  Client referred to case manager for assistance with housing, but no documentation that housing status was assessed  Case management assessment and service plan differ as to clients needs. Assessment may indicate “no need identified” in a particular area, but this need addressed in service plan.  Goals for client identified then dropped

16 OBSERVATIONS  Successful Strategies  Documentation is handled as if third party, unfamiliar with agency, will be reading it  Charts are structured to systematically follow the service delivery and standard of care  Use of forms and flow charts for intake, assessment, primary care indicators  Uniform training and policy for documentation  Electronic medical record – addresses issues of legibility and organization