Framework for Good Report Writing. Assessor Meeting April 11, 2016 Dr. Keith Hay and Dr. Nathan Roth

Transcription

1 Framework for Good Report Writing Assessor Meeting April 11, 2016 Dr. Keith Hay and Dr. Nathan Roth

2 Presenter Disclosure Dr. Keith Hay, CPSO Medical Advisor Relationships with commercial interests: none Potential for conflict(s) of interest: none Dr. Nathan Roth, CPSO Medical Advisor Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: Merck Consulting Fees: Cancer Care Ontario Potential for conflict(s) of interest: none

3 Who Needs Assessments? Quality Management Division Investigations and Resolutions Department

4 Objectives for this Session After this session, participants will be able to: Discuss some of the challenges encountered in report writing. Identify key elements of a good assessment report. Describe differing expectations of reporting based on the assessor role.

5 Challenges of Writing a Good Report Getting doctor in trouble The contrarian physician Determining care versus record keeping issues Physician versus the system

6 Writing a Good Report the Challenges I don t want someone to lose their licence because of my report

7 Writing a Good Report the Challenges What to do about the physician who is not open to suggestions or disagrees with the assessor?

8 Writing a Good Report the Challenges How to sort out if care is adequate in the face of poor records?

9 Challenges to Writing a Good Report What about systems issues?

10 A Bad Report Please write down one component of a bad report on your index card.

11 Challenges Writing a Report Please write down one challenge you have faced when writing a report on the other side of the index card.

12 Components of a Good Report

13 Components of a Good Report Appropriately edited Concise and logically organised Acronyms only if required Evidence based Unbiased Clear summary

14 Components of a Good Report Edited

15 Components of a Good Report Concise Logically organized Factual Tell the story

16 An Example A focused history and physical exam are obtained and documented Pertinent positive and negative findings are noted Investigations and blood work are appropriate Co-morbidities are documented and considered in the treatment plan High-risk patients are referred for pre-operative evaluation

17 Components of a Good Report Acronyms

18 Report using Acronyms DM flow sheet used. HA1C on OHA - triple therapy. BP, LDL, ACR at target. Monofilament and opthalmic testing complete. Pneumovax complete. FOBT, Td, Flu, PSA not documented.

19 Components of a Good Report Based on relevant guidelines, practice standards and literature

20 An Example using Evidence The patient was called in to review her lab results showing high lipid levels She had a known history of hypertension Dr explained what those levels meant in terms of the Framingham risk score for future potential cardiac events The patient was counseled about diet and lifestyle She also offered a lipid-lowering medication as per the guidelines

21 Components of a Good Report Unbiased and Fair

22 Components of a Good Report Summary

23 Peer Assessment Reports

24 How To Strengthen my Peer Assessment Report Changes from peer redesign Survey of College staff and QAC members

25 How To Strengthen my Peer Assessment Report - General Use clear objective language Include positive as well as negative aspects of care in the report

26 How To Strengthen my Peer Assessment Report - General Clarify when record keeping is the issue versus care concerns Distinguish between what is done but not documented, and what is neither done nor documented Incorporate issues clarified in the interview throughout the report

27 Documentation Deficiencies complete R of S; pt healthy; BP was high 149/79 and was started on Altace 5 mg any other readings? start BP meds with one reading? what about low salt and weight loss and exercise? not discussed? or just not marked in chart? we discussed this afterwards Dr stated that he does discuss low salt diet and exercise and weight loss with pts with HTN but does not mark this in chart

28 Using Interview Information In my opinion the exam documentation was too brief for the severity of the presentation. At the interview, Dr. was able to describe a more thorough assessment/examination that would meet the standard of care.

29 How To Strengthen my Peer Assessment Report Tick Boxes Flag what is good Make recommendations for improvement

30 Recommendations The history, physical examination and investigations were consistently excellent. While Dr. uses a CPP, the medication portion is not always up-to-date. I recommended he give the same attention to this aspect of the record as he does other elements.

31 How To Strengthen my Peer Assessment Report Chart Review Avoid a too detailed review of the history and examination

32 Chart Review S: Cold and cough for 2 weeks. No fever. No chills. No phlegm. No runny nose. No tearing of eyes. Has sick contact at home. No travel outside of country. ls getting better. O: Patient not in distress. Afebrile. HEENT exam was normal. Respiratory system was clear with air entry normal bilaterally. No cervical lymphadenopathy. No accessory muscle use. No nasal flaring. A: Viral upper respiratory tract infection. P: Hydration. Lots of fresh citrus fruits. OTC vitamin C. Follow-up in case of worsening or no relief.

33 Chart Review Patient presented with signs and symptoms of a viral upper respiratory tract infection A thorough history and physical exam was documented Patient was managed appropriately

34 How To Strengthen my Peer Assessment Report Chart Review Too few comments in the chart review leaves the Committee wondering if all is well or if the assessment was an inadequate

35 Chart Review G3P2 female was seen for a 1st prenatal visit Antenatal records were appropriately filled out A physical exam was done and recorded Her pap test was updated consistent with current guidelines Appropriate investigations were done She was counseled and pursued IPS Referral to a local obstetrician was noted in the chart

36 Chart Review The form is filled in and a referral was made for obstetrical care.

37 How To Strengthen my Peer Assessment Report Care Concerns If there are care concerns try to gauge: severity in terms of degree of risk is the concern isolated or is there a pattern of care Offer a clear explanation when a concern is identified

38 Care Concerns I am concerned about this patient s drug treatment. Given a history of peptic ulcer disease, prescribing Mobicox, Naprosyn and Arthrotec must be done with caution furthermore, the patient may have been selfmedicating with Advil, increasing the risk of severe adverse effects such as gastrointestinal hemorrhage.

39 How To Strengthen my Peer Assessment Report - Summary Provide a brief overview of the physician s practice The summary should reflect: the tone of the assessment important practice strengths and weaknesses the physician s knowledge base and if practice is evidence-based a review of recommendations/concerns physician s receptivity to feedback

40 Summary Example Dr. is a busy family physician in Ontario and belongs to a FHO. He provides care to approximately 2000 patients in his office practice and participates in a walk-in clinic as part of his call group. He practices contemporary, evidence-based medicine, prescribes appropriately and provides good preventative care. He is a kind, empathetic physician and was receptive to my suggestions concerning a more comprehensive medical record.

41 How To Strengthen my Peer Assessment Report - Summary Would you be comfortable assuming patient care based on the assessed physician s charting?

42 Summary Example I felt my review of Dr. s charting was favorable. His notes were easy to follow and I felt that anyone could take over his patients and would know what were the issues and what was being planned.

43 How To Strengthen my Peer Assessment Report Be consistent Clarify care concerns Incorporate components of the interview Make suggestions for practice improvement Keep chart reviews concise Summarise

44 Checklist Peer Assessment Checklist is now available

45 Did you remember to?

46 Investigative Reports

47 How to Strengthen my I & R Report thanlroth.mp4?download=1

48 Checklist For Medical Inspectors

49 Checklist For Independent Opinion Providers

50 Questions?