Discharge Documentation Audit Jure Baloh, Julie Brandt, PhD, Douglas Wakefield, PhD, Becky Morton, RHIA, Kay Davis, PhD, RN, Robert Hodge, MD Center for Health Care Quality, University of Missouri, Columbia, Missouri, USA Discharge Documentation Audit Jure Baloh, Julie Brandt, PhD, Douglas Wakefield, PhD, Becky Morton, RHIA, Kay Davis, PhD, RN, Robert Hodge, MD Center for Health Care Quality, University of Missouri, Columbia, Missouri, USA Background The objective of the study was to determine the compliance rates of different services at the University of Missouri Health Care regarding the discharge documentation requirements and standards set by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC). Recommendations 1. Include the provider’s contact number on the Depart Summary Determine if contact number can be automatically added based on provider or service 2. Update the Provider Content of the Medical Record policy to reflect current practice Review the current policy and make recommendations for revisions based on Electronic record changes, Change in procedure for discharge documentation, TJC and CMS requirements, and Meaningful Use requirements 3. Review and analyze best practices by service Prioritize the required data elements by importance to patient care and follow up, Determine best practices (heat map), Review processes and specific records to find examples, Set standards for optimal documentation at discharge 4. Improvement plan developed for each service Education for providers who document discharge information 5. Set compliance rates for each service and audit regularly Determine what percent of records meeting each criteria is acceptable for each service 6. Standardize data elements required in each document Review and require specific data elements that must be included in the three documents so that it is clear to the care giver where they will find the information needed to care for the patient Define “referring” and “primary care” physician (internal and external) Analyze how we use current technology to make creation and compilation of the discharge information easier and more efficient 7. Review documentation requirements for outpatient surgery patients Define discharge documentation needs for patients seen in Same Day Surgery and in Short Stay status. Results Requirements and Standards ADMISSION NOTE: Completed within 30 days prior/24 hours after admission, Patient’s name is correctly listed on document, Chief complaint, History of present illness (HPI), Past medical history, Past surgical history, Allergies, Medications on admission, Social history, Review of body systems, Physical examination, Pertinent lab results, Pertinent radiology results, Assessment and plan of care DISCHARGE SUMMARY : Document dictated or created within 3 days of discharge, Patient’s name is correctly listed on document, Reason for hospitalization or HPI, Hospital course and results of treatment, Pertinent lab results, Pertinent radiology results, Procedures performed, Patient’s condition and disposition at discharge PATIENT DEPART SUMMARY : Provider to complete the discharge summary (and the discharge order), Name of the attending physician, Name of the physician at discharge, Referring Physician, Primary care provider, Contains the patient’s correct name, Contains correct date and time of discharge, Document is created at the time of discharge, Final diagnosis is listed, Follow up care is listed or none indicated, Follow up appointments are listed, Medications the patient should take are listed, Patient instructions including activity and diet, Notify physician if specific symptoms appear, Physician contact information All in all, there were 300 missing documents (27% of 1086). 78 Patient records (21% of 362) did not have any of the 3 documents Samples There have been 6609 discharges from 29 services in the period from 3/1/2011 to 5/31/ services (labeled XA - XG) were excluded from the study. From the remaining 22 services, 362 samples were randomly selected following the system on the right  service# of dischargessample size% A % B943202% C701203% D676203% E578203% F496204% G384205% H371205% I220209% J % K % L % M % N901011% O781013% P741014% R651015% S381026% T18 100% U17 100% V15 100% Z22 XA11400% XB3000% XC300% XD200% XE100% XF100% XG100% Total % Audit Tool Discharge Service:ABCDEFGHIJKLMNOPRSTUVZALL Number of Discharges Sample Size Requirements and Standards: ADMISSION NOTE Completed 30 days prior/24 hrs after adm. 95%80%90% 100%95%75%40%65%85%75%60%15%70%80%50%100%80%0%82%7%50% 68% Patient’s name is correctly listed 100%70%90%70%100%95%75%40%70%80%75%70%15%70%100%50%100%90%0%88%7%50% 68% Chief Complaint 100%70%90%70% 95%70%40%50%80%75%60%15%70%100%10%100%90%0%82%7%50% 63% History of Present Illness 100%75%90%75%95% 75%40%50%80%75%70%15%70%100%10%100%90%0%88%7%50% 66% Past medical history 100%70%90%60%100%95%70%40%75% 65%10%70%100%50%100%90%0%82%7%50% 67% Past surgical history 85%70%30%65%90%80%45%40%65%70% 65%10%70%100%50%80%90%0%76%7%50% 58% Allergies 100%70%75%60%100%95%60%35%70%80%75%65%15%70%100%10%80%90%0%88%7%50% 64% Medications on admission 95%70%65%55%80%95%55%40%75%80%75%70%15%70%100%30%90% 0%88%7%50% 63% Social History 100%65%90%60%100%90%70%40%75%70% 15%70% 10%100%90%0%35%7%50% 62% Review of Body Systems 100%70%60%85%95% 70%35%75%80%70%65%15%70%90%10%100%80%0%88%7%50% 65% Physical Examination 100%65%80%65%70%95%75%40%75%90%75%70%15%70%100%10%100%90%0%88%7%50% 65% Pertinent lab results 100%45%65%15%70%85%60%35%60%55%40%65%10%50% 10%90% 0%18%7%0% 48% Pertinent radiology results 75%45%0%50%60%65%55%25%65%35%40%45%0%60%50%10%60%80%0%29%0% 39% Assessment and plan of care 100%75%90%75%70%95%75%40%75%85%75%70%15%70%100%10%100%90%0%88%7%50% 67% DISCHARGE SUMMARY Dictated/created within 3 days of discharge 95%60%50%65%70%95%40% 70%50%75%55%15%20%50%0%90%100%0%65%7%50% 54% Patient’s name is correctly listed 100%80%90%80%90%100%70%40%90%45%75%70%15%80%90%10%100%90%0%53%7%50% 65% Reason for hospitalization or HPI 100%80%100%70%90%100%70%40%90%70%75%65%15%80%90%10%100% 0%82%7%50% 68% Hospital course and results of treatment 100%80%100%85%90%100%70%40%90%65%75%65%15%80%90%10%100% 0%76%7%50% 68% Pertinent lab results 90%10%90%0%85%95%35%25%0% 55%15%30%0% 100% 0%35%0%50% 35% Pertinent radiology results 70%35%5%10%50%75%40%25% 0%5%50%0%50%10% 40%90%0%35%0% 28% Procedures performed 90%70%25%85%90%40%45%15%60%55% 45%15%80%70%10%50%70%0%41%7%0% 48% Pt’s condition and disposition at discharge 80%65%100%70%45%60%55%15%85%55%65%55%5%70%90%10%80%90%0%41%7%0% 53% DEPART Provider to complete the Discharge Summary 95%50%45%20%60%55%45%35% 25%0%20%0%20%0% 80% 0% 50% 32% Attending Physician (for the visit) 100% 90%95%90%65%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 73% Contains name of physician at discharge 100%90%100%90%95% 65%40%90%95%80%40%10%70%100%20%100% 0%88%7%50% 70% Referring Physician 35%25%15%25%55%10%25%10%30%35%20%25%0%40%30%50%10%20%0%29%7%50% 23% Primary Care Provider 85%50% 45%65%95%45%30%55%75%65%50%5%60% 40%60%70%0%65%7%50% 51% Contains the patient’s correct name 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 74% Contains correct date and time of discharge 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 74% Document is created at the time of discharge 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 74% Final (Discharge) Diagnosis is listed 100% 90%95% 70%40%90%95%80%55%10%70%100%50%100% 0%88%7%50% 72% Follow up care is listed, or none indicated 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 74% Follow up appointments are listed 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 74% Meds the pt should take are listed 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50% 74% Pt instructions, including activity and diet 95%90%85%80%85%90%60%25%85%100%80%35%5%70%90%0%80%90%0%65%7%0% 63% Notify physician if specific symptoms appear 55%65%70% 75%45%30%5%15%85%20%30%0%70%40%20%50%30%0%71%7%0% 41% Physician contact information 10%15%70% 35%0% 5%85%5%0% 50%20%0%20%10%0%53%0% 22% AVERAGE=91%70%76%67%82%83%59%33%67%72%62%56%10%66%78%25%85%86%0%71%6%39%59% Pt. visit# (FIN): Discharge Service:AAAAAABBBBCCC ADMISSION NOTE OLD SCAN Powernote or Transcribed?pptptptptptpt Completed within 30 days prior/24 hrs after adm.yyyyyyyyynyyy Patient’s name is correctly listed on documentyyyyyyyyyyyyy Chief Complaintyyyyyyyyyyyyy History of Present Illnessyyyyyyyyyyyyy Past medical historyyyyyyyyyyyyyy Past surgical historyyyyyyynyyyyyy Allergiesyyyyyyyyyyyyy Medications on admissionyyyyynyyyyyyy Social Historyyyyyyyyyyyyyy Review of Body Systemsyyyyyyyyyyyyy Physical Examinationyyyyyyyyyyyyy Pertinent lab resultsyyyyyyyyyyyyy Pertinent radiology resultsyyyyynynyyynn Assessment and plan of careyyyyyyyyyyyyy DISCHARGE SUMMARY MISS Powernote or Transcribed?pppp ppppppp Dictated or created within 3 days of dischargeyyyy yyyyyyn Patient’s name is correctly listed on documentyyyy yyyyyyy Reason for hospitalization or HPIyyyy yyyyyyy Hospital course and results of treatmentyyyy yyyyyyy Pertinent lab resultsyyyy yyyyyyn Pertinent radiology resultsyyyn yyyynyn Procedures performedyyyy yyyyyyn Patient’s condition and disposition at dischargeyyyy ynyyyyy PATIENT DEPART SUMMARY EXP Provider to complete the Discharge Summaryyyyyyy yyyyyy Attending Physician (for the visit)yyyyyy yyyyyy AUDIT TOOL LEGEND: p: Powernote; t: Transcribed y: Requirement/standard met n: Requirement/standard not met OLD: The document was created at another visit (within the required timeframe) SCAN: The document was a scanned form MISS: The document was missing EXP: The patient expired during the stay AUDIT TOOL LEGEND: p: Powernote; t: Transcribed y: Requirement/standard met n: Requirement/standard not met OLD: The document was created at another visit (within the required timeframe) SCAN: The document was a scanned form MISS: The document was missing EXP: The patient expired during the stay

Discharge Service:ABCDEFGHIJKLMNOPRSTUVZALL Number of Discharges Sample Size Requirements and Standards: ADMISSION NOTE Completed 30 days prior/24 hrs after adm. 95%80%90% 100%95%75%40%65%85%75%60%15%70%80%50%100%80%0%82%7%50%68% Patient’s name is correctly listed 100%70%90%70%100%95%75%40%70%80%75%70%15%70%100%50%100%90%0%88%7%50%68% Chief Complaint 100%70%90%70% 95%70%40%50%80%75%60%15%70%100%10%100%90%0%82%7%50%63% History of Present Illness 100%75%90%75%95% 75%40%50%80%75%70%15%70%100%10%100%90%0%88%7%50%66% Past medical history 100%70%90%60%100%95%70%40%75% 65%10%70%100%50%100%90%0%82%7%50%67% Past surgical history 85%70%30%65%90%80%45%40%65%70% 65%10%70%100%50%80%90%0%76%7%50%58% Allergies 100%70%75%60%100%95%60%35%70%80%75%65%15%70%100%10%80%90%0%88%7%50%64% Medications on admission 95%70%65%55%80%95%55%40%75%80%75%70%15%70%100%30%90% 0%88%7%50%63% Social History 100%65%90%60%100%90%70%40%75%70% 15%70% 10%100%90%0%35%7%50%62% Review of Body Systems 100%70%60%85%95% 70%35%75%80%70%65%15%70%90%10%100%80%0%88%7%50%65% Physical Examination 100%65%80%65%70%95%75%40%75%90%75%70%15%70%100%10%100%90%0%88%7%50%65% Pertinent lab results 100%45%65%15%70%85%60%35%60%55%40%65%10%50% 10%90% 0%18%7%0%48% Pertinent radiology results 75%45%0%50%60%65%55%25%65%35%40%45%0%60%50%10%60%80%0%29%0% 39% Assessment and plan of care 100%75%90%75%70%95%75%40%75%85%75%70%15%70%100%10%100%90%0%88%7%50%67% DISCHARGE SUMMARY Dictated/created within 3 days of discharge 95%60%50%65%70%95%40% 70%50%75%55%15%20%50%0%90%100%0%65%7%50%54% Patient’s name is correctly listed 100%80%90%80%90%100%70%40%90%45%75%70%15%80%90%10%100%90%0%53%7%50%65% Reason for hospitalization or HPI 100%80%100%70%90%100%70%40%90%70%75%65%15%80%90%10%100% 0%82%7%50%68% Hospital course and results of treatment 100%80%100%85%90%100%70%40%90%65%75%65%15%80%90%10%100% 0%76%7%50%68% Pertinent lab results 90%10%90%0%85%95%35%25%0% 55%15%30%0% 100% 0%35%0%50%35% Pertinent radiology results 70%35%5%10%50%75%40%25% 0%5%50%0%50%10% 40%90%0%35%0% 28% Procedures performed 90%70%25%85%90%40%45%15%60%55% 45%15%80%70%10%50%70%0%41%7%0%48% Pt’s condition and disposition at discharge 80%65%100%70%45%60%55%15%85%55%65%55%5%70%90%10%80%90%0%41%7%0%53% DEPART Provider to complete the Discharge Summary 95%50%45%20%60%55%45%35% 25%0%20%0%20%0% 80% 0% 50%32% Attending Physician (for the visit) 100% 90%95%90%65%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%73% Contains name of physician at discharge 100%90%100%90%95% 65%40%90%95%80%40%10%70%100%20%100% 0%88%7%50%70% Referring Physician 35%25%15%25%55%10%25%10%30%35%20%25%0%40%30%50%10%20%0%29%7%50%23% Primary Care Provider 85%50% 45%65%95%45%30%55%75%65%50%5%60% 40%60%70%0%65%7%50%51% Contains the patient’s correct name 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%74% Contains correct date and time of discharge 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%74% Document is created at the time of discharge 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%74% Final (Discharge) Diagnosis is listed 100% 90%95% 70%40%90%95%80%55%10%70%100%50%100% 0%88%7%50%72% Follow up care is listed, or none indicated 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%74% Follow up appointments are listed 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%74% Meds the pt should take are listed 100% 90%95% 70%40%90%100%80%65%10%80%100%50%100% 0%100%7%50%74% Pt instructions, including activity and diet 95%90%85%80%85%90%60%25%85%100%80%35%5%70%90%0%80%90%0%65%7%0%63% Notify physician if specific symptoms appear 55%65%70% 75%45%30%5%15%85%20%30%0%70%40%20%50%30%0%71%7%0%41% Physician contact information 10%15%70% 35%0% 5%85%5%0% 50%20%0%20%10%0%53%0% 22% AVERAGE= 91%70%76%67%82%83%59%33%67%72%62%56%10%66%78%25%85%86%0%71%6%39%59%