Template Sample Medical History Form 138 by bho25192

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									138 – Point of Care
 Record Reviews
         Patricia Powles, RHIA
Nebraska-Western Iowa Healthcare System
           Kathy Kelley, CCS
 James E. Van Zandt VAMC, Altoona, PA
        VA Nebraska-Western Iowa
           Health Care System
• Divisions:
  – Omaha, Lincoln, Grand Island


• CBOCs:
  – Norfolk, North Platte, Holdrege, Bellevue
    and Shenandoah




                                                2
    VA Nebraska-Western Iowa
Health Care System Omaha Division




                                    3
                    NWIHCS
• Acute Inpatient Care at Omaha
• Outpatient Care all sites
• Nursing Home Care at Grand Island
• Specialties: primary care, medicine, surgery,
  psychiatry, physical medicine and rehabilitation,
  neurology, oncology, dentistry, and geriatrics.
• Affiliated with University of Nebraska Medical
  Center and Creighton University
• Clinical Research


                                                      4
          Medical Record Reviews


•   Point of Care
•   Post-Discharge Review
•   Special Joint Commission Review
•   Tracking of Incomplete and Delinquent
    Records




                                            5
                  Goals
• Facilitate communication between
   clinicians and those responsible for
   monitoring medical record documentation.
• Reduce the number and average age of
   incomplete and delinquent documents.
 • Improve reporting processes for
   management.



                                              6
    Joint Commission Requirement



The focus of ongoing medical
record reviews is to be
documentation available at the
point of care.



                                   7
            Purpose of Reviews
• Ensure that medical records are readily
  available, complete, secure, and contain
  sufficient entries to: assure continuity of
  information to meet the patient's needs;
• Document the services provided;
• Record the outcome of each episode of care;
  and otherwise meet all current requirements for
  a medico-legal document.
• The process will also ensure that the provider(s)
  responsible for the care and treatment of each
  patient is clearly identified.



                                                      8
         Sample Encompasses
• Currently hospitalized or being treated,
• Patients who have been discharged,
• Patients who are receiving services on an
  ambulatory basis




                                              9
                 Basic Review
• Patient identification and legal status/surrogate
  (if any).
• Reports of consultation(s) and
  operative/invasive procedure(s) including
  appropriate informed consent.
• Reports of diagnostic or therapeutic
  interventions such as clinical laboratory, surgical
  pathology, imaging, etc., and their appropriate
  authentication.
• Timely signature and filing of reports of
  operation/invasive procedure.



                                                    10
          Basic Review Con’t.
• Known advance directives.
• Recording of all medications
  ordered/prescribed/
  administered/dispensed and any
  associated adverse reaction.
• Ambulatory Care information including a
  listing of diagnoses, procedures, drug
  allergies, and medications
  prescribed/dispensed.


                                            11
   REPORTS
Monthly Delinquency
      Report
          Excel Spreadsheet
• Compiled Monthly
• Based on daily reports from VISTA
• Daily figures compiled by Coding &
  Transcription
• Reported to Medical Records Committee
  and Executive Committee




                                          13
14
15
Graphs




         16
Graphs




         17
Graphs




         18
Graph




        19
Graphs




         20
                  Actions
• Medical Records Committee reviews
  results monthly.
• Recommendations are made and sent on
  to the Executive Committee
• Chiefs of Medicine, Surgery and Psych are
  responsible for addressing the deficiencies
  with their staff including Residents.



                                           21
           Sample of Records
• Adequate to validly assess the scope of
  care provide the NWICHS
• Reviews most the most important
  diagnosis/procedures;
• those situations posing unusual risk or
  problems will be selected for abstraction
  and review.



                                              22
   Point of Care Medical Record Reviews
• Ongoing documentation reviews by
  caregivers who make the entries in the
  record while the patient is treated.
• Results in immediate corrective action;
  opportunities for improvement related to
  accurate, complete, and timely
  documentation.
• Ensures better communication between
  caregivers
• Ultimately improving the quality of care and
  safety for the patient.



                                                 23
          Point of Care Reviews
• History and Physical recorded within 24
  hours of admission and prior to all elective
  invasive procedure;
• History includes history of the present
  illness, relevant other history and body
  system review;
• Physical examination, and an inventory of
  age related psycho-social needs.


                                             24
        Point of Care Reviews Con’t.
•   Informed Consent (paper or I-Med)
•   Advanced Directive
•   Pre-Op Orders
•   Tests
•   Medications Given




                                        25
   Sample from CPRS Template
NURSING OR PREP NOTE (T)


  Preoperative Checklist:           Yes
  Preop orders noted:               Yes
  History and Physical completed:   Yes
  History & Physical updated:       Yes
  EKG completed:                    Yes
  CXR completed:                    Yes
  Other Radiology Tests done:       Yes
  Type and Screen ordered:          Yes
  Type and Cross ordered:           Yes
  Medications given:                 Yes




                                           26
     Sample from CPRS Template
NURSING OR PREP NOTE (T)


   ID verified with patient:                 Yes
   Anesthesia Note entered:                  Yes
   Inp Nursing Assessment completed:         Yes
   Consent obtained:                         Yes
   Paper Consent on chart:                   N/A
   Surgical site marked:                     Yes
   Does patient have an advance directive?   No




                                                   27
          Sample from CPRS Template
LOCAL TITLE: NURSING PREOP CHECKLIST (T)
Preoperative Check List
Preop orders noted Jan 30,2008
History and Physical Completed Jan 20,2008
EKG Jan 21,2008
Chest x-ray Jan 21,2008
Labs
CBC Jan 28,2008
UA
Metabolic profile Jan 30,2008
Coag studies Jan 30,2008
Blood: type and screen Jan 29,2008
Blood: crossmatch 2 units

NPO since MN Jan 29,2008
Prosthetics & personal effects removed
Voided Jan 30,2008
Patient on beta blocker: Yes
Metoprolol
Dosage: 25 mg Time given: Jan 29,2008@21:00




                                              28
         Sample from CPRS Template
LOCAL TITLE: Surgery Attending Pre Op Note (t)
STANDARD TITLE: SURGERY ATTENDING PRE OPERATIVE E & M NOTE

Diagnosis:

Procedure/Treatment:

Labs reviewed:

Patient seen during rounds. Case discussed with the Residents
and/or mid-level provider.

Assessment/Plan: Resident/Mid-Level Provider Note reviewed and agree
with Assessment/Plan.




                                                                       29
            Sample from CPRS Template

LOCAL TITLE: Surgery Post Op Note (t)
STANDARD TITLE: SURGERY POST OPERATIVE E & M NOTE

POST-OP NOTE

PRE-OP DIAGNOSIS:
POST-OP DIAGNOSIS:
OPERATIVE PROCEDURE:
FINDINGS:
SURGICAL SPECIALTY:
SURGEON (RESIDENT):
SPECIMENS REMOVED:
ANESTHESIA:
EST. BLOOD LOSS: DRAIN(S):
COMMENTS/COMPLICATIONS:

POST-OP CONDITION:

Findings reviewed and concurred with staff surgeon.




                                                      30
  Presence and Timeliness of the History and Physical

• Presence of attending admission note
• Resident supervision requirements for attending
   admit note
• Signature and co-signature of the H&P
  Business Rules Set-up to ensure capture of
   attending on Resident H & Ps
• Seen by the attending within 24 hours of admit
• Documented by COB day after admission
• Attending findings and recommendations


                                                        31
       Unapproved Abbreviations
• Class III software
• Identifies Text Documents where
  Unapproved Abbreviations were used.
• NWIHCS reviews for the Joint
  Commission Unsafe Abbreviations
• Identifies the author, the patient, and the
  text where the abbreviation was used.
• Can be run by Service, Division, Providers
• Run and reported monthly to the Services

                                            32
       Post-Discharge Reviews


Discharge Summary Components
Discharge Summary adequately describes:
• Reason for hospitalization
• Significant Findings
• Procedures performed and care & tx
• Patient's condition at discharge
• Instructions to the patient/family



                                          33
            Joint Commission
• Special follow-up Medical Record Review
  for Post-Procedure Notes specifically
  regarding:
  • Flexible Sigmoidoscopies
  • Cystoscopies




                                            34
Post-Procedure Review Audit Form




                                   35
Post-Procedure Review




                        36
Post-Procedure Note Review for Cystoscopies




                                              37
Concurrent Review




                    38
Concurrent Review




                    39
               Conclusion
• The Medical Record Review function is a
  formal process for reviewing the timely
  completion, accuracy, and authentication
  of medical records; to assure compliance
  with current standards of the Joint
  Commission on Accreditation of
  Healthcare Organizations and to promote
  performance improvement.



                                             40
James E. Van Zandt VA Medical
           Center
    Altoona, Pennsylvania




                                41
       JEVZ VA Medical Center
Medical Center in Altoona, PA
 Acute Inpatient Care
 Community Learning Center (CLC)
 Outpatient Primary Care
 Specialty Clinics
CBOC’s
 Johnstown, Dubois and State College


                                       42
JEVZ VA Medical Center Process




                                 43
   Point of Care Medical Record Reviews
• Point of care medical record reviews are
  ongoing documentation reviews done by
  caregivers who make entries in the record while
  the patient is being treated, resulting in
  immediate corrective action to identified
  opportunities for improvement as it relates to
  accurate, complete, and timely documentation,
  ensuring better communication among
  caregivers which ultimately results in quality care
  and safety for the patient.


                                                   44
        Joint Commission Standards

• IM.6.10 ~ EP 12
  – Medical records are reviewed on an ongoing basis at the
    point of care
• IM.6.10 ~ EP 13
  – The review of medical records is based on hospital-defined
    indicators that address the presence, timeliness,
    readability (whether handwritten or printed), quality,
    consistency, clarity, accuracy, completeness, and
    authentication of data and information contained within the
    record




                                                              45
                    History
• Prior to 2006
  – All medical record reviews were done by
    HIMS
• Implemented in FY 2006
  – Point of care record reviews done at the time
    of service by the caregivers documenting in
    the medical record




                                                    46
    138 – Point of Care Record Reviews

• Process
• Responsibilities
• Sample sizes
• Development of calendar and review
  sheets
• Coordinating the process
• Preparing reports



                                         47
                  PROCESS
The Medical Record Committee will annually
  review the medical record review process
  and make recommendations for change. The
  Medical Record Committee reserves the
  option of developing clinical indicators for the
  facility to be used in the medical record
  review process based on high-volume, high
  risk, problem prone indicators and to assure
  the integrity and accuracy of the hospital-
  defined indicator thus assuring a compliant
  medical record review process.



                                                48
                    Process
• Memos to the services
  – Early summer
  – Indicators for each clinical area/program
    • Primary Care, Inpatient, ER, HBPC, etc.
  – Joint Commission standards, high-risk, high-
    volume, problem –prone
• Proposed indicators reviewed by Medical
  Record Committee
• Establishment of thresholds


                                                   49
                   Responsibilities
• Responsibilities
  – Coordinator
     • Provide training
     • Develop review calendar and review sheets
     • Identify patients
  – Service Chiefs
     • Designate staff to perform reviews
     • Assure reviews are submitted timely
  – Designated staff
  – Medical Staff Reviews
     • Second level reviews



                                                   50
                Sample Sizes

• Statistically valid sample sizes as defined
  by the Joint Commission
  – Population size of less than 30 – 100%
    Review
  – Population size of up to 100 – sample 30
    cases
  – Population size of 101 to 500 – sample 50
    cases
  – Population size of 500 – sample 70 cases


                                                51
             Time Parameters
• Inpatients and NHCU
  – At the time care & treatment is given
• Ambulatory Surgery
  – At time care is being given
• Outpatient records
  – Within 30 days of the date of service




                                            52
                 Review Sheets
• Multi-disciplinary Reviews
  – All patients to be reviewed will be identified by
    coordinator
  – Patients will be identified through-out the review
    month until sample size is reached
• Service Specific Reviews
  – Service will get the appropriate number of blank
    review sheets at the beginning of the review
    period
     • Quarterly
     • Semi-Annually



                                                         53
        Development of Calendar
• Monthly
  – Inpatient, Outpatient Procedures, Primary
    Care, Behavioral Health, Specialty Clinic, ER,
    Pain Clinic, Anti-Coagulation Clinic
• Quarterly
  – Long Term Care, HBPC, Critical Results, etc.
• Semi-Annual (low volume)
  – Dental, Prosthetics, Home Oxygen



                                                 54
55
56
    Development of Review Sheets
• Multi-disciplinary Reviews
  – All indicators from the various disciplines
    combined on one review sheet
• Service Specific Reviews
• Review sheets approved by Medical
  Record Committee before implementation




                                                  57
Sample Review Sheet




                      58
Sample Review Sheet




                      59
               Coordination
• HIMS staff
  – Prepare training materials
  – Develops annual calendar of reviews
  – Determines sample sizes
  – Identify patients
  – Track return of review sheets
  – Medical Staff reviews
  – Inter-rater reliability reviews



                                          60
Coordination




               61
Patients to Review




                     62
          Second Level Reviews
• HIMS completes reviews for Medical Staff
  indicators
• Review sheets are sent to the services
• Requested to do a second level review
  – Concur or Do Not Concur
  – Prior to reports being submitted to Medical
    Record Committee




                                                  63
                     Reporting
• Enter the data
  – Plato Data Analyzer
• Compile statistics
• Reports
     • Red/Green report
     • Individual reports
• Service Responsibility for Action Plans



                                            64
RED/GREEN REPORT




                   65
Reports




          66
             Reliability Review
• Inter-rater Reliability Reviews
  – Validate the process
  – Assure the highest degree of accuracy




                                            67
                   Benefits
•   Services own part of the process
•   Services are aware of the results
•   Immediate corrective action
•   Better communication
•   Distributes the work




                                        68
            Timeliness Reports
• Monthly
  – Dictation of Discharge Summaries
  – Discharge Record Completion
  – Observation Record Completion
  – Outpatient Surgery Record Completion
  – Dictation of Operative Reports
  – Signing of Operative Reports
  – Timeliness of Post-op Progress Note



                                           69
               Timeliness Reports
• Monthly (continued)
  –   Timeliness of H&Ps – Admissions
  –   Timeliness of H&Ps – Inpatient Surgery
  –   Timeliness of H&Ps – Ambulatory Surgery
  –   Encounters in VistA with associated electronic
      progress note
  –   Unsigned/uncosigned documents
  –   Delinquent documents
  –   Average number of unsigned documents
  –   Unsigned Orders
  –   Timeliness of Gynecology-Cytology cases
  –   Timeliness of Radiology Reports



                                                       70
Red/Green Report for Timeliness




                                  71
Red/Green Report for Timeliness




                                  72
Timeliness Reports




                     73
Graphs




         74
75

								
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