How Important Is It

1
How Important Is It?
Documentation, Documentation, Documentation

• November 21, 2008
• Charley Borden
• AIDS Institute

2
IIWNDIDNH
3
AGENDA 900 - 930am Breakfast
Registration 930 - 945am Welcome,
Introductions Review Agenda 945 -
1030am Overview of Documentation
Challenges 1030 - 1100am Small and Large
Group Impact on Quality 1100 -
1115am Break 1115 - 1145am Root Causes
Exercise 1145 - 1220pm Strategies for
Improvement 1220 - 1230pm Wrap-up and
Evaluation
4
Introductions

• Name
• Program
• Role / Title
• Why is this topic of interest to you?

5
Quality Improvement Approach

• Identify problem
• Cost of not fixing
• Root Cause(s)
• Possible Solutions
• Implement
• Monitor

• What?
• So what?
• Why?
• How?
• Do something!
• Hows it going?

6
Documentation Challenges

• This section of workshop from presentation
• NYCHSROs Experience in Title 1 Quality
  Management Review
• Harriet Starr
• Vice President, Government Contracts
• New York County Health Services Review
  Organization

7
ISSUES IN THE QUALITY OF MEDICAL RECORD
DOCUMENTATION

• Timely and accurate documentation is
• 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

7
8
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

8
9
NEW YORK COUNTY HEALTH SERVICES REVIEW
ORGANIZATION (NYCHSRO)

• Reviewed the following programs
• Case Management
• Treatment Adherence
• Food and Nutrition
• Home Care
• TB DOT
• Harm Reduction

9
10
NYCHSROs EXPERIENCE

• Reviewed approximately
• 2700 records at 74 programs in 2005
• 2900 records at 44 programs in 2006
• 3000 records at 49 programs expected for 2007

10
11
OBSERVATIONS

• Critical information not documented
• No ARV medications documented
• 1 page barrier assessment form used, but form
  omitted Primary Care Access as a barrier
• No documentation for months at a time. Was
  client disenrolled from program?
• Lists of community food and nutrition services
  provided at intake, automatically or on request,
  but not documented in client record

11
12
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

12
13
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

13
14
OBSERVATIONS

• Incomplete record documentation stored in too
  many places
• Documentation of treatment education sessions
  not kept in chart
• Dates of educational sessions stored in
  different location than topic
• Intake information only kept in oldest of
  multiple charts

14
15
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 Treatment Adherence or Food Nutrition chart
• Demographics only in URS, not in chart

15
16
OBSERVATIONS

• Documentation is too general
• Schedule of educational sessions provided no
  topic available
• Topic of educational session identified only as
  education, and not specific to HIV

16
17
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 clients primary
  medical care and mental health visits

17
18
OBSERVATIONS

• Documentation is illegible
• Illegible handwriting in notes
• Cant identify provider cant read signature
• Photocopies too light or smeared/distorted
• 3rd or 4th copy of multipart form nothing
  legible

18
19
OBSERVATIONS

• Inconsistencies among documentation
• HIV medications listed in progress notes but
  absent from client reassessment
• Electronic and paper records have discrepancies
  in list of HIV medications
• Goals for client identified then dropped

19
20
OBSERVATIONS

• Inconsistencies among documentation (continued)
• 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.

20
21
Review Plus

• Not documented
• Not dated
• Disorganized
• Incomplete
• Too many places
• Too general
• Illegible
• Inconsistencies

• Unapproved Abbreviations
• Medications Incorrect
• Patient
• Drug
• Dose
• Time
• Route
• Allergies missing
• Problem list incomplete
• Demographics incorrect
• Others???

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
So what?

• Inability to do the best work
• Patient Safety
• Seek to identify errors and near-miss events
• Dana-Farber Cancer Institute
• Fair and Just Culture
• Any documentation problems ? patient error or
  near-miss examples from participants?

26
Learning to improve patient safety

• Patient Safety Incident any unintended or
  unexpected event that led to death, disability,
  injury, disease or suffering for one or more
  patients
• Near Miss Any situation that could have
  resulted in an accident, injury or illness for a
  patient, but did not due to chance or timely
  intervention by another

27
Prescription Sheet
Allergy to penicillin
Check Medical Notes
Poor training of personnel
Transcription
Drug Labelling System
Patient Information System
Drug Info System
Other systems
Medical Records System

The latent failure model of complex system
failuremodified from James Reason, 1991
28
(No Transcript)
29
Small/Large Group Discussion

• Brainstorm/Discuss
• What could go wrong, (or at least not go well),
  as a result of documentation problems?
• Not CAUSES of poor documentation, thats coming
  next
• Start with patient but think beyond as well

30
Did we mention

• Uninformed decisions
• Limits communication
• Less than optimal patient outcomes
• Lose reimbursement
• Lose accreditation/license
• Legal risk individuals and organization
• Limits performance measurement and research
  opportunities

31
BREAK
32
Causes of documentation problems

• Why
• Why
• Why
• Why
• Why
• STICKIES and FISHBONES

33
Successful Strategies from Harriet Starr

• 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.
• Forms include all indicators.

33
34
Successful Strategiesfrom Harriet Starr

• Uniform training and policy for documentation
• Electronic medical record addresses issues of
  legibility and organization

34
35
Successful Strategiesfrom IHI

• Hard-wire (create a routine)
• Standardized forms
• Flow charts outlining sequence of steps
• Communications (who tells who what, when)
• Accelerate return of lab results (Joint QI
  project?)
• Use stamps or stickers

36
Example

• Case Management Progress Note Documentation

37
Case Management Progress Note Documentation

• First option- SOAP Model
• The term SOAP notes refers to a particular
  format of recording information regarding client
  treatment procedures. Documentation of services
  delivered and treatment plan is an extremely
  important part of the service delivery process.
  SOAP notes are the most popular format in
  medical, supportive and health care settings.

38
Case Management Progress Note Documentation

• SOAP notes consist of information presented in
  the following order
• Subjective
• This part of your notation should describe your
  impressions of the client/patient. For example
  David was eager to complete the tasks presented
  to him today.
• This section should be utilized to report
  subjective information of clinical significance.
  The statement Billy was a cute little boy with
  blue eyes. is a subjective statement, however,
  this observation would probably not be clinically
  significant with respect to the treatment of this
  patient.

39
Case Management Progress Note Documentation

• Objective
• This section is where you will report the
  measurable and observable information that you
  obtain during the client session.
• Remember that this section can be used to report
  behaviors that you observe, not just the
  behaviors that you are targeting. Key element is
  documentation that substantiates services
  offered. For example, the designated case manager
  identified that Billy was uncomfortable
  discussing family related issues as a result of
  his past substance abuse history.

40
Case Management Progress Note Documentation

• Assessment
• This section is where you assess, in descriptive
  terms, the clients performance during the
  session and/or the session itself. For example
  Billys interest in support groups has
  increased, as a result his individual counseling
  sessions have decreased due to his continued
  involvement and supportive treatment

41
Case Management Progress Note Documentation

• Plan
• The final section of your SOAP notes is where you
  outline the course of action, treatment plans
  etc., after considering the information you
  gathered during the individual session. Billy
  will continue to participate in supportive group
  counseling to promote self-sufficiency, identify
  long term goals and address his continued
  involvement/timeframe in program services.

42
Case Management Progress Note Documentation

• PIP notes consist of information presented in the
  following order
• Problem-client presenting needs, reason for
  referral, involvement in program services etc.
• Intervention-staff involvement with determining
  client needs, referral sources, his/her role
  while client is involved in program, next steps
  in care.
• Plan of Outcome-Action plan to address client
  short and long term needs, care coordination,
  successful referral and involvement in care etc.
  

43
Monitoring

• Existing Measures
• Needed Measures
• Chart Reviews
• Self
• Peer
• Internal Reporting
• To who?
• Used how?

44
(No Transcript)
45
Take Home

• In pairs
• What can I do next week?
• Individually
• Team
• Share

46
QuestionsWorkshop EvaluationTHANK YOU!!!