Post on 30-Mar-2015
Metro North
Dispelling Bad Documentation Habits in Clinicians Early
Michelle Leeding – Health Information Manager
Debbie Tansacha – Medical Education Officer
Metro North Health Service District
The Journey
Metro North Health Service District
Setting the scene Background rationale Medical Education Unit Intern Program Lessons Learnt Where to from here?
Overview
Metro North Health Service District
Setting the Scene
Metro North Health Service District
Setting the Scene
Metro North Health Service District
Recommendation from Coroner’s Report
Establishment of new HIMS position Improvement of Intern Orientation
program
Background Rationale
Metro North Health Service District
Coroner’s Report
Black, T,J. 2008. Inquest into the cause and circumstances surrounding the death of Kenneth Maggable on 9 August 2005, Findings.
Background RationaleBackground Rationale
Metro North Health Service District
Background Rationale
Health Information Management Service
Medical Education Unit
Background Rationale
Metro North Health Service District
Role:Coordinates the education and training of Resident Medical Officers (Intern to PHO) within Redcliffe Hospital in line with accreditation standards and medical registration regulations
Medical Education UnitMedical Education Unit
Metro North Health Service District
1. Orientation / debrief
2. End of Term Audits
3. End of Term Reports / Statistics
4. End of Term Interview process
5. Mid year group results
6. End of year comparative analysis
Intern Program: Phases
Metro North Health Service District
Intern Program: Orientation
Metro North Health Service District
Mabel Smith: 79yo female
Admitted to Orthopaedic Ward
Fractured Neck of Femur
Initial pain relief in EDPMH: Ischaemic Heart Disease, Type II Diabetes
SxH: Widowed, lives alone
Allergy: Cephalexin
Case Study 1
Metro North Health Service District
TASK 1: Write up the admission progress notes in the chart provided
TASK 2: Write up Medication ChartTASK 3: Complete Discharge Script
Case Study 1: Tasks
Metro North Health Service District
…6 months later, Presentation to ED
Community acquired pneumonia complicated by her past medical history
Blood glucose levels unstable
Minor dehydration Impaired renal function
Case Study 2
Metro North Health Service District
TASK 1: Find and review Resus Plan in Chart provided. Identify key elements to consider
TASK 2: Write up Insulin Order
TASK 3: Complete a Death Certificate
Case Study 2: Tasks
Metro North Health Service District
Audit Results Clinical Coding Feedback from
Interns
Orientation: Debrief
Metro North Health Service District
End of Term Audit & Reports
Metro North Health Service District
End of Term Interview processEnd of Term Interviews
Metro North Health Service District
Mid Year Group Results
Metro North Health Service District
Annual Report Group results Comparison with overall hospital
documentation results
Awards Best overall result
End of Year Analysis
Metro North Health Service District
Intern’s Perspective
Metro North Health Service District
Lessons LearntLessons Learnt
Metro North Health Service District
Where to from here?