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.