Physician Physician DocumentationDocumentation

Improvement ProjectImprovement Project

HIM Vital Role In ImprovingPhysician Documentation

Historical Historical BackgroundBackground

Project Purpose, Goal and Recommendations

• Medical Staff Leadership identified a need to improve the quality of physician documentation.

• Physician Documentation Improvement Committee, comprised primarily of physicians, was established to champion this need.

• Project was established with primary goal to improve physician efficiency and documentation.

Historical BackgroundHistorical Background

• Develop tools to support more robust, thorough and accurate notes.

• Establish an audit process to measure and assess compliance on documentation standards.

• Conduct pilot audit to determine effectiveness of tool.

Where To BeginWhere To Begin

• Audit results revealed that utilization of the new electronic tool did not necessarily facilitate improved physician documentation.

• Ongoing, more in-depth audits were proposed…

But, to be done by whom

Pilot Pilot Findings/RecommendFindings/Recommendationsations

Handoff to HIMHandoff to HIM

Project Development StageObstacles

Implementation

• HIM Department was solicited by Physician Documentation Improvement Committee to take on the challenge of ongoing record audits.

Handoff to HIM (HIM Handoff to HIM (HIM to the Rescue)to the Rescue)

• It was felt the project best fit within the scope of the departmental Regulatory Auditing Process & the HIM Regulatory Manager was approached with the challenge.

Handoff to HIMHandoff to HIM

• Staffing Considerations• Revision and Evaluation of Audit Tool• Audit Process Established• Database Developed (Audit and Reporting

Tools)

Project Development Project Development StageStage

• Soliciting Physician Reviewers

• Physician Training

Project Development Project Development StageStage

• Physician Reviewer Contracts

• Technical Issues

ObstaclesObstacles

Road Maps to Keep Road Maps to Keep Us GoingUs Going

Documentation of Workflowand Processes

• Policies and Procedures • Project workflow• Job Aids/Instructions for audit completion• Physician Invoicing

Documentation of Documentation of Workflow and ProcessesWorkflow and Processes

• Reporting Process Established to include:• Reports to PDI Committee • Hospital VPMAs• Hospital Quality Improvement Committees

Outcome Reporting of Outcome Reporting of Audit ResultsAudit Results

What’s on the What’s on the Horizon…Horizon…

New Auditing Initiatives

• Discharge Summary Review

• Data Replication, Cloning, Cutting and Pasting

New Auditing New Auditing InitiativesInitiatives

THE ENDTHE ENDNo… It’s just the

beginning…

QUESTIONSQUESTIONS