Reviewing Effective & Accurate Documentation: READ Workshop Introductory Presentation

Goals Understand importance of documentation  Patient care “hand-offs”/covering for colleagues health care transitions (hospital discharge)  Billing & Coding  Quality improvement & performance evaluation  Legal document Learn key elements for various types of notes Develop good habits NOW (at start of career) Meet/exceed ACGME requirements

You are the intern on-call on Friday and are covering for your colleagues who recently signed-out. At 5pm, you are called urgently by the nurse to evaluate a patient who has become less responsive than baseline. The “primary nurse” has gone for a break. You look to your sign-out sheet for some information on the patient, but there is no mention of his mental status. You locate the chart and walk into the room where you are greeted by the patient’s extended family who has just arrived from out of state. Upon opening the chart to review the situation, you see that the intern has yet to put her progress note on the chart. Fortunately, the attending note IS present… Case

Direct data on patient outcomes lacking Indirect data exists  More “handoffs”  more adverse events  Improved “sign-out”  fewer adverse events  Accurate problem list on chart  proper medications  Discharge summary available  lower rate readmission Does documentation matter?

Effect on billing Note reflects  Complexity  Time  Expertise Does documentation matter?

Effect on billing  Teaching service patients  more payments generated for hospital ? Due to extensive documentation ? Due to ordering of extra tests ? Confounded by degree of medical complexity  Teaching attendings documentation (as pertains to billing) worse than non-teaching attendings Effective documentation  viable practice Does documentation matter?

Inpatient chart review & feedback  reduction in lab ordering by 47% Daily chart review in ED  decrease in charting errors by 10% Chart review in outpatient clinic  improved chart documentation Formal teaching program re: dictation  improved quality of discharge summaries Can documentation be taught?

READ Workshop developed and implemented at IM program in CT Positive feedback from housestaff and faculty Formal program evaluation in progress

Ground-Rules Constructive criticism Honest criticism No personal attacks Strive to protect confidentiality  Patient  Author of note

Divide into small groups (4-5 per group) Read first note to yourself (2 min) Assign “scribe” for your group Discuss note using template provided (5 min) Scribes from each small group present summary (2 min) Scribes submit paperwork to me  Summary template for group  Comments written directly on the note READ Workshop