Department of Medicine Performance Improvement Record Completion.
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Transcript of Department of Medicine Performance Improvement Record Completion.
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 e-mail notification of outstanding records. “waiting for Dr… to dictate” upgrade.
Data Trending
Medicine Discharge Summary Trending
050
100150200
Dictations Signatures
Delinquent Record Detail
Resident Attending
Date Dictations Signatures
1/11/2007 161 179
3/28/2007 130 156
6/27/2007 88 152
10/31/2007 26 92
1/30/2008 62 41
4/28/2008 84 22
7/31/2008 43 38
10/31/2008 73 44
1/30/2009 36 44
4/17/2009 37 44
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.