Department of Medicine Performance Improvement Record Completion
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.
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.
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 notification of outstanding records. “waiting for Dr… to dictate” upgrade.
Data Trending
Delinquent Record Detail ResidentAttending DateDictationsSignatures 1/11/ /28/ /27/ /31/ /30/ /28/ /31/ /31/ /30/ /17/
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
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.