HEALTH RECORD REVIEW PRACTICE BRIEF May 2005

Transcription

1 Health Information Management Office of Health Data and Informatics HEALTH RECORD REVIEW PRACTICE BRIEF May 2005 Part 1: Introductory Guide INTRODUCTION The purpose of this Guide is to recommend processes for an effective, ongoing health record review program, including authentication and completion of health record documentation. All VHA sites must design and implement a health record review program as part of their site s overall information management, performance measurement and quality management systems. The health record review program will need to continually change and improve as regulations and accreditation standards evolve to meet increasing demands for accountability. Health record reviews meet many requirements, including mandatory reporting for regulatory and accreditation as well as for performance monitoring, record completion and quality improvement. Health Information Management s (HIMS) role in the design and deployment of a health record review program is a vital part in the umbrella of information management. Performance measures are used to evaluate many important aspects of health care, including how we are doing, if we are meeting goals, if our Veterans are satisfied, if our processes are appropriate and if and where improvements are necessary. Many performance measures in quality management require review of health record documentation. GUIDING PRINCIPLES In setting up or modifying an already existing health record review function, an important guiding principle is to incorporate all health record review activities into one encompassing, integrated health record review program, even if the program crosses organizational boundaries. All staff involved in any aspect of the health record review program need to understand the scope of review activities in order to minimize redundant reviews and conflicting data definitions. The reasons for an integrated program include: Developing a holistic view and management of health record activities Prioritizing interventions for improvement Identifying mechanisms to utilize resources more efficiently Reducing the number and average age of incomplete and delinquent documents 1

2 Improving reporting processes for management, and Facilitating communication between clinicians and those responsible for tracking documentation trends. Getting Started Key health record review requirements for VHA stem from accrediting agencies and the VA. Examples include the JCAHO, VA OIG, CARF, VA s Academic Affiliations Office, VA performance monitors, etc. In planning the program, consider the following: What Needs Monitoring? What are current priorities for VHA in general, your site specifically, accrediting and/or regulatory agencies? Of these priorities, what areas lend themselves to health record review? What performance measures would provide information to make a difference in how we are doing, if we are meeting our goals, if our customers are satisfied, if our processes are in control and/or if and where improvements are necessary? What aspects of care and documentation need and/or require100% monitoring and/or review? What aspects require periodic monitoring, how often, and what sampling methodologies may be employed? What is an appropriate sample size? How frequently should each review be conducted and/or reported? Where can data collection, analysis and display make a difference? How much realistically can we really do? What canned reports or automated data are available? Who are Collaborative Stakeholders? Who are the medical center executives who are responsible to ensure a review process is in place? Which clinical staff are willing to champion the review process? Who already conducts or could participate in health record reviews? Usually, one thinks of HIM and Quality Management (QM) data analysts. There are others who could also perform this type of review: service line or department managers, administrative officers, business managers, various clinicians, etc. What would motivate stakeholders to participate in such a program? Who decides when and what to collect? Who creates and maintains the data dictionaries? (Yes, you need one of these!) A data dictionary is a descriptive list of data elements to be collected from the health record; the purpose of the list is to ensure consistent usage. 2

3 Reporting Structure What reporting structures make sense in your facility? Remember, it is important to provide your entire organization with a picture of how well the organization is performing and the areas that need improvement? It is also important to report results to leaders who will be able to understand the importance of the data and will plan appropriate action. Can you present information on your intranet? What kind of privacy, confidentiality and security do you need? Data Presentation Data should be presented in such a way that information and trends can be readily understood. Graphical displays should always include a narrative description of what is being measured including the standards, what the data means, where, when and how it was collected, a summary of the findings, recommendations for improvement, and when and how the changes are being followed up, including a date for re-review. Performance Improvement Plans Whatever group is receiving the report should be responsible for planning or delegating actions for implementation, when required. TYPES OF REVIEW Accreditation Accrediting bodies such as the JCAHO have always included standards that incorporate some type of ongoing health record review. Since January 1, 2004, the JCAHO is no longer prescriptive. Instead, IM.6.10 requires an organization to conduct reviews at the point of care based upon defined indicators that address the following elements: Presence -- is the required data available? Timeliness -- are documents available according to standards, organization policy, state or federal laws? Is adequate documentation created to support safe, quality patient care? Readability (whether handwritten or printed) -- Are the entries legible and easy to read? Quality -- Does the documentation reflect an accurate picture of the care and treatment provided? Is it meaningful and appropriate to the encounter? Consistency -- Does the record consistently reflect good standards of documentation practices and principles? Are the forms or computer screens standardized? Clarity -- Are all entries clear in their meaning? Accuracy -- Are entries free from error and according to documentation guidelines? 3

4 Completeness -- Does the health record contain all the reports and documentation to support the treatment provided? Authentication -- Has the health record been validated for correctness for both the information itself and the person who is the author of the information? The subject of health record reviews, however, is now left up to the discretion of the individual healthcare organization. VA Requirements Resident Supervision For those sites that have residents, the most current handbook, VA Handbook , states that resident supervision must be monitored in the following care settings when residents are involved: Inpatient care Outpatient care Procedural care Emergency care Consultative care Surgical care, including a review of the appropriateness of levels E and F. The Handbook goes on to require that the following documentation also be incorporated into overall resident supervision monitoring: Results of health record reviews and other locally derived quality management data Incident reports and tort claims Risk events, including adverse events and near misses Patient complaints Externally derived quality management data, including EPRP data. OIG Recommendations VA s OIG recommends health record reviews of many of the same subject areas as does the JCAHO, although sometimes with a more specific criterion or outcome. These subject areas may change from time to time. History & Physical Operative/Invasive Procedure Report Post-procedure note Discharge Summary Informed Consent Advance Directive Initial Assessment/Re-Assessment Care/Treatment Planning 4

5 JCAHO National Patient Safety Goals Do Not Use Abbreviations Read back of verbal orders/critical values Resident Supervision Medical Necessity Other Project and Quality Improvement Projects Focused reviews, special projects, documentation improvement activities may all give rise to health record review criteria and/or health record reviews. Any of these reviews should be coordinated and reported through the appropriate facility oversight committee(s). Again, it is important to use consistent data definitions and prevent wasted time through redundant reviews. It may be that data previously collected needs to be analyzed from a different viewpoint to meet a new need. For example, data collected to track delinquency can also be used to pinpoint timeliness of documentation. Most providers and allied health providers already have documentation reviews taking place. Be sure to evaluate what is already being done and integrate the appropriate reviews, findings and follow up into your Health Record Review process. Record Completion Process In this process, tracking is done primarily for presence, timeliness and authentication of health record documentation. STAGES IN HEALTH RECORD REVIEW There are four main stages in a health record review program: Stage 1: Performance Measurement. a. What to measure. One must first decide what patient record documentation and/or patient care processes need to be measured. Standards organizations, as well as VHA itself, suggest and require that certain performance measures be developed for specific areas. These requirements change from time to time so it is important to check with the most recent edition of the standards, VHA handbooks, directives, etc. Additionally, it is important to align performance measurement with other key organization strategic objectives and action plans. b. Who has oversight? There may be several entities within your organization who perform oversight for various health record review activities: the Health record Committee, a CPRS Steering Committee, a Quality Management Committee, various department and/or service line committees. If there is more than one oversight committee, it is valuable to collaborate on what topics are required and/or selected for 5

6 review over a year s time, how often and when the data will be collected, and who is responsible to collect, collate, display and analyze the data. c. What are the performance goals or standards? Compare the collected data against the established standards. Stage 2. Performance Analysis. What kind of analyses performed? Organizations need to convert raw data into performance information and knowledge so recommendations can be made for improvement, or for monitoring changes. Analysis should evaluate such factors as compliance with standards, whether a process is under control, and if patterns are discernable in the data. Stage 3. Communication. Results must be communicated to the staff and areas in the organization that have the decision-making authority. This may include the Medical Record Committee and/or the Clinical Executive Board as well as service line or service line leaders, executive leaders and/or VISN and other oversight bodies. Stage 4. Follow-up. Oversight bodies that receive on-going reports need to promulgate a plan for continued monitoring that includes improvement activities and focused reviews as needed. STEPS IN IMPLEMENTING THE 4-STAGE PROCESS The following steps are recommended. Stage 1: Performance Measurement 1. Define your facility s delinquent record and incorporate the definition with the timeframe in the Medical Staff Bylaws, Rules and Regulations. 2. Decide what documents will be reviewed for authentication, who will conduct the review and how often. 3. Establish data definitions to clarify what elements are to be examined, what criteria will be measured, where to look for the information and what evidence is required. 4. Establish relevant documentation standards. 5. Identify documentation practices and business rules, including: Document titles used Key documents not included in CPRS Signatures and co-signatures required by either title or document class 6

7 Document viewability ; e.g., can unsigned notes be viewed? Can un-cosigned resident notes be viewed? Etc. 6. Choose what elements of the record will be reviewed for completeness and quality. 7. Decide with whom, when and how you are going to share reports. 8. Notify appropriate clinical leadership about the project; solicit their input. 9. Create a tool that allows for the easy collection and integration of review data. This may be on paper, in a spreadsheet, or database; the key is that the data be readily extractable. Stage 2: Performance Analysis 10. Create lists of incomplete or missing documents by printing lists from IRT and TIU. 11. Import the lists into Excel. 12. Sort the lists by author, service, note title, patient, co-signer, status, etc. as needed. 13. Create queries or data reports for data elements, to sort and collect information. 14. Format lists to best meet the needs of the responsible staff. (Administrative support staff, management, clinical chiefs, etc.) 15. Review lists and other data looking for problems, compliance, trends (positive or negative). 16. Lock the document from accidental or other changes. Stage 3: Communication 17. Save the document to a secure, shared location or print and distribute hard copy reports. 18. Inform authorized, responsible staff that the information is available. 19. Create clear, trended reports for health record committee, clinical executive board and other oversight groups appropriate to your site.* 20. CELEBRATE your successes as they happen! Give recognition for improved performance as well as for exceptional performance. 21. Require plans and deadlines for actions to correct negative findings or trends. Stage 4: Follow-up Hold the Gains 22. Regularly, validate the data contained in any list. For example, make sure that undictated Discharge Summaries have not been entered as a progress note or that the flags in IRT failed to reset. 23. Validate the data definitions. Be sure that what you think you are looking at is what is documented. Also, data definitions may need to be changed over time. 24. Evaluate the need for ongoing reviews. Increase or decrease the frequency of reviews based on benchmarking and findings. Change monitors as organizational needs and practices change. For example, in CPRS there is no 7

8 longer a need to monitor that the patient s name and SSN are on every page; the system automatically does that. * Remember, data should be presented in such a way that information and trends can be readily understood. Graphical displays should always include a narrative description of what is being measured including the standards, what the data means, where, when and how it was collected, a summary of the findings, and recommendations for improvement. 8

9 MEDICAL RECORD REVIEW GUIDE Part 2: Medical Record Review Case Study PURPOSE The purpose of this section is to demonstrate a model process for reviewing, monitoring and reporting medical record reviews and tracking incomplete and delinquent health record authentication in order to: Reduce the number and average age of incomplete and delinquent documents, Improve reporting processes for management, and Facilitate communication between clinicians and those responsible for monitoring medical record documentation. This model addresses two parts of a medical record review process; first, how to review and report medical record qualitative and quantitative analysis, and secondly, how to track lack of authentication on TIU documents, including discharge summaries, addenda, operative reports and notes. According to JCAHO, the focus of ongoing record reviews is to be at the point of care. There is no mention of reviews after discharge, but HIM can still conduct reviews for items including discharge summaries (timeliness, content, authentication), autopsy reports (timeliness, content, authentication) and other reports such as H & Ps, operative reports, consults, signatures, etc. INTRODUCTION One VA site has developed a medical record review program through the collaboration of HIMS, the Quality Improvement department, Education and the clinical services. Items to be reviewed, the frequency of reviews, sample size and responsibility for collection and reporting of data have all been defined. A vital component of the review program is a set of data definitions that are published and used by everyone to understand how components are defined, where to look for them in the record, and how to answer the data collection questions regarding each component. This information is available as a separate document. Results from reviews, as well as status and trends in incomplete documentation, are reported regularly to the clinical service lines for action and monitoring, and to the CPRS/CHR Steering committee (our medical record committee) as well as to the Clinical Executive Board. Prior to implementation, the proposed plan, including report format and communication strategy, was shared with executive and clinical leadership. Input was sought and incorporated; this site has always had strong support from clinical leadership. 1

10 Types of Reviews Reviews conducted by HIMS staff include both 100% and focused reviews: 100% Reviews Reviews study admission event documentation, including: Presence and timeliness of the H&P Signature and co-signature of the H&P Presence of required H&P elements: o Chief complaint o Details of present illness o Relevant past history o Social history o Family history o Inventory of body systems o Plan Presence of attending admission note Resident supervision requirements for attending admit note Seen by the attending within 24 hours of admit Documented by COB day after admission Attending findings and recommendations Focused Reviews Focused documentation reviews are conducted one week per quarter to one week per month for the following documentation: Unapproved abbreviations Informed consent for surgical procedures Admission and discharge notes Discharge summary components o Diagnoses (including Axis IV and V for Psychiatry) o Abbreviations in diagnoses o Disposition o Medications o Activity restrictions o Condition on discharge o Diet o Follow-up o Discharge instructions Advance Care Directives Patient Assessments (still pending definition) Wet orders 2

11 Phone/Verbal orders Patient identification Electronic Data Collection Tool Example This VA site chose to develop and employ an electronic data collection tool using Microsoft Access in order to take advantage of its automated data tabulation and extraction functionality. Forms used to collect data are created and completed in an Access database. Samples of the forms used are: SAMPLE 100% Admission Event Review, including H&P s and Resident Supervision 3

12 SAMPLE Focused Review Form SAMPLE Outpatient Surgical Review Form Note: The form for inpatient surgical reviews is very similar excluding the informed consent portion. 4

13 Tracking Incomplete and Delinquent Medical Record Documentation Program Decisions When creating their program, this site made the following policy decisions: Records are considered delinquent if they remain incomplete 30 days after discharge or surgery. This site chooses to track only discharge summaries and operative reports for delinquency. The site tracks other items in its ongoing record review. For example, this site does not include H & Ps in its delinquency tracking because they are tracked real time for percentage completion, at the point of care, as part of ongoing record review. There is no value in creating an H&P after discharge. Similarly, unsigned orders are not tracked under the delinquency definition because action has already been taken or has failed to take place for which the site is equally liable regardless of signature. Also, Orders are viewable regardless of signature status. All documents are grouped into notes or discharge summary classes and includes uploading C & P exams as TIU note titles. All key documents, including scanned non-va documents are included in CPRS. Business rules have been established by user class and document title to require signature and, if appropriate, co-signature. Most notes are not viewable until complete, including co-signature if required. H & Ps, operative reports and discharge summaries are viewable with only a resident s signature. Clean up the IRT list. Initially, it took the site several weeks to validate every entry in IRT. If the software is working properly, it should remain accurate for discharge summary dictation. All other deficiencies, except operative report dictation, were cleared from IRT. Operative report deficiencies for dictation must be manually entered into IRT. Report Creation The site regularly generates three lists and imports them into Excel. The lists are: the Unsigned Orders List, the TIU List for Progress Notes and Addenda and the Discharge Summary and Operative Reports (unsigned/uncosigned and undictated) List. The following procedures delineate how to create these lists. Unsigned Orders List 1. Open up the unsigned orders instructions document for instructions. 2. Pull data in VistAfrom the Unsigned Orders Search Menu for the date range of T- 60 to T Import data into excel and format columns. 4. Add specialty and cosigner to each note. 5. Copy and Paste data into the orders template. 5

14 6. Rearrange data in the template 7. Rename template TIU List (progress notes and addendums) 1. Open up the progress notes instructions and addendum instructions documents for instructions. 2. Pull data in VistA from Text Integrated Utilities menu for the date range of April 1, 2001 to T Import data into excel and format columns. 4. Add specialty and cosigner to each note. 5. Copy and paste data into the unsigned TIU documents template. 6. Rearrange data in the template. 7. Rename template. Discharge Summary and Operative Reports (unsigned/uncosigned and undictated) 1. Open up the unsigned discharge instructions and undictated discharge instructions documents for instructions. 2. Pull data from two menus in VistA a. Unsigned/Uncosigned discharge summaries and operative reports from Text Integrated Utilities menu for the date range of June, 1, 1999 to T-1 b. Undictated discharge summaries and operative reports from Incomplete Records Tracking menu (IRT) for the date range of June, 1, 1999 to T Import data in excel and format columns. 4. Add specialty an cosigner to each document. 5. Copy and paste data into the incomplete records template. 6. Rearrange data in the template. 7. Rename template. Note 1: The site uses these resources to help determine specialties and cosigners: Social work phone list helps with progress notes Monthly surgical and peri-operative care resident rotation list Monthly medicine resident rotation list Telephone directory in VistA Note 2: This teaching site modified the Fileman routine that generates list outputs to include service data for the author and the co-signer. A list of unsigned orders is generated by service. 6

15 Importing into Excel and Generating Reports After generating the lists, they are Imported into Excel and sorted. Each list is printed to the screen and captured as a text file. Open the text file in Excel and insert column breaks as required. Caution: Different sites use different emulation software. Capture mechanisms may vary. Check with your IRM or ADPAC for instructions. Sorting. The site sorts each list by division, service line, co-signer and author. The list is broken down to separate tabs (worksheets) within the Excel workbook by division and service. An All Services tab is all-inclusive and makes it easy to search by patient and to generate facility numbers. Here are examples of two of the sorted reports: SAMPLE Weekly incomplete TIU Document Report SAMPLE Delinquent Record List (Published Weekly) Formatting. Columns within the spreadsheet are sequenced to allow responsible staff within each service access to the information they need. Color-coding is used to 7

16 differentiate document age. For example, red designates a delinquent, over 30-day document. Reports For incomplete documentation: The lists are password-protected to prevent accidental changes or deletions. The lists are posted weekly to a LAN workgroup that designated staff and management in each service line may access. All designated staff and management are included in an Outlook mail group that receives weekly notices with hot links to the lists. Following is a sample of the with hotlinks: SAMPLE Weekly Outlook SAMPLE Delinquent Medical Records (Summaries and Operative Reports) 8

17 For database reviews: Reports are generated from the database at regular reporting intervals, or upon request. Reports can be generated at the facility, service, specialty, or even provider level. Here are two examples: SAMPLE Resident Supervision Report 9

18 SAMPLE Presence of Discharge Summary Elements Report Reporting. Trended reports showing service line information for both signatures and dictation are generated and sent to the Medical Record Committee and the CEB. This site chose to share information using weekly Excel spreadsheets broadcast via the Local Area Network through a secure workgroup with responsible staff throughout the facility. An message informs staff as new lists are posted. Monthly, status reports with trended data are shared with the medical record committee. Quarterly, trended information by service line is shared with the Clinical Executive Board. As stressed in Part I of this paper, data should be presented in such a way that trends can be readily understood. Graphical displays should always include a narrative description of what is being measured including standards, what the data means, where, when and how it was collected, a summary of the findings and recommendations for improvement. Following is an example: 10

19 SAMPLE Medical Record Briefing 4/1/2004 Resident Supervision, FY 04 Trend YTD. Requirements: 1. Does the Attending physician meet and physically examine each patient within 24 hours of admission? and 2. Does the Attending document his/her findings and recommendations not later than the close of business the day after admission? The data show that as a medical center we have not made any significant progress in either increasing the overall compliance with the national performance monitor, nor in the evidence of exam within 24 hours. The national performance monitor is looking at only the second criterion and expects 85% or better compliance; 90% is exceptional. This facility, however, is continuing to differentiate between those cases that clearly meet both criteria and those that only meet the second criterion. Recommended action: Service and specialty-specific lists, including Attending names, are available in G:\WORKGRPS\CVAR Reports\Resident Supervision. Please review the lists, looking for trends within your Service Line and take appropriate action. 11

20 Quality Control. Monthly, 100% of the list of undictated Discharge Summaries is manually reviewed. Weekly, the list of undicated Operative Reports is manually reviewed. Because the Operative Report deficiencies are manually entered into IRT, there is a greater chance of error. CELEBRATE! Recognition is given in multiple forums for improved and/or excellent performance. At least once a year, the HIM Chief presents positive achievements to the Clinical Executive Board. 12

21 Part 3: References HEALTH RECORD REVIEW GUIDE Following are examples of one facility s reference material for health record reviews. First is an example of what a data definition may look like. Also, find excerpts from hospital policies related to review elements and a glossary of terms used in this document. Advance Directives Instructions: Sample Data Definition for Focused Reviews 1. Documentation about Advance Directives (AD) may be found in one or more of the following: Nursing Administrative Assessment Template (NAAT) Patient Administrative Template (MH) (PAAT) Attending Note Resident Note Social Worker Note Advance Directive Progress Note Template 2. IF documentation shows THEN find the AND check AND the patient check Was asked about an AD YES Said s/he wants an AD or information about an AD Could not respond to any questions about AD preferences or provider could not ask family member provider consultation (usually to a social worker) YES NA Has an AD AD in the paper or computerized record if the AD is scanned flagged and readable Note: If any missing or questionable, contact the Document Scanning Supervisor Does not have an AD NO YES 1

22 Excerpt CLINICAL BULLETIN JUNE 2005 Attachment A Unapproved Abbreviations and Symbols for Handwritten, Free-Text Computer Entry, Pre-Printed Forms and Templates for Medical Record Entries Abbreviation/Symbol Potential Problem Preferred Term U (for unit) IU (for international unit) Q.D., Q.O.D. (Latin abbreviation for once daily and every other day) Trailing zero (X.0 mg), Lack of leading zero (.X mg) MS MSO 4 MgSO 4 Mistaken as zero, four or cc. Mistaken as IV (intravenous) or 10 (ten). Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I". Decimal point is missed. Confused for one another. Can mean morphine sulfate or magnesium sulfate. Write "unit" Write "international unit" Write "daily" and "every other day" Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg) Write "morphine sulfate" or "magnesium sulfate" 2

23 Excerpt CLINICAL BULLETIN 03-7 OCTOBER 2003 a. Telephone orders (1) If the clinician is in the facility and initiating the call for non-emergency orders, the clinician is to enter the order(s) directly into CPRS and notify the nurse of the new order. (2) If clinical staff (e.g., a nurse) is initiating a call with an emergent request to a clinician who is not in the facility (e.g., at night), the clinical staff member must write the order(s) down or enter it/them into CPRS, and read-back the order(s) to the clinician for confirmation. The confirmed orders are to be entered into CPRS as telephone orders as soon as possible, but no later than the end of the shift. The ordering clinician will be identified as the requesting clinician and will receive a View Alert to sign the orders. The orders are to be electronically signed within 24 hours unless they occur on a weekend, in which case signature is required on the first day after return to duty. In the event the orders are not timely signed, the Service Line is responsible for having the orders signed within seven (7) calendar days by a Service Line clinician authorized to sign such orders. b. Verbal orders (1) Verbal orders may be accepted only in emergencies, or in situations in which the clinician is unable to do computer entry (e.g., clinician is gloved). The person accepting the orders must write the orders down or enter them into CPRS, and readback the orders to the clinician for confirmation. The confirmed orders are to be entered into CPRS as verbal orders as soon as possible, but no later than the end of the shift. The ordering clinician will be identified as the requesting clinician and will receive a View Alert to sign the orders. The orders are to be electronically signed within 24 hours. In the event the orders are not timely signed, the Service Line is responsible for having the orders signed within seven (7) calendar days by a Service Line clinician authorized to sign such orders. Verbal orders may be accepted in these situations by the following: (a) Registered Nurses for patients under their professional care; (b) Respiratory Therapists for orders pertinent to their specialty; (c) Registered Pharmacists for patients under their professional care, or for orders pertinent to their specialty; (d) Clinical Dietitians for orders pertinent to their specialty; (e) Laboratory personnel for orders pertinent to their specialty. (2) During a code, if it is not feasible for the person who should carry out the orders, e.g., the nurse, to write the orders down before doing a read-back, then a repeatback to the clinician for confirmation is acceptable. Verbal orders are to be written on the code sheet and signed by the clinician as soon as the code has ended, and the code sheet filed in the paper chart. Verbal orders during the code are to be entered into CPRS and designated as Signature on Chart or Written. 3

24 Glossary of Terms (used for this Practice Brief) Authentication may include written signature, written initials or electronic signatures. Business Rules authorize specific users or groups of users to perform specified actions on documents in a particular status; e.g., a practitioner who is also the expected signer of the note may edit an Unsigned Progress Note. Sites can modify or add to these rules to meet local needs. A consultation is a service performed when an opinion or advice regarding evaluation and/or management of a specific problem is requested. A data dictionary is a descriptive list of data elements to be collected from the health record; the purpose of the list is to ensure consistent usage. A delinquent record is an incomplete record that has not been finished within the timeframe specified in the facility's medical staff Bylaws, rules and regulations but not to exceed 30 days. Documentation is the written or computer-generated health record evidence of a patient encounter. In terms of resident supervision, documentation is the written or computer-generated health record evidence of the interaction between a supervising practitioner and a resident concerning a patient encounter An incomplete record is a patient record that is missing content, reports and/or authentications, as defined by medical staff Bylaws and/or facility policy. The Incomplete Record Tracking (IRT) menu [DGJ IRT MENU] is a VistA package that tracks incomplete text entries in the health record. There are site specific parameters that can be set; e.g., what documents to track. A health record review program is a coordinated, integrated cross-organizational effort to measure and improve health record documentation and documentation practices to support patient care and clinical processes. Performance improvement is a structured activity to introduce fundamental changes to achieve higher levels of performance. It represents the introduction of beneficial change. Performance improvement is changing the status quo. Quality is the degree to which a product or service meets requirements and expectations. Quality improvement (QI) is the process of improving medical care and potentially decreasing healthcare costs. QI review activities can be carried out on a concurrent or retrospective basis. Concurrent review occurs while care is being given or documented. 4

25 Retrospective review occurs after patient discharge or following an outpatient visit. A resident is an individual who is engaged in a graduate training program in medicine, dentistry, podiatry, or optometry and who participates in patient care under the direction of supervising practitioners. Programs must be accredited or certified as appropriate. Supervision is an intervention provided by a supervising practitioner to a resident. Supervising Practitioner is a licensed, independent physician, dentist, podiatrist or optometrist, regardless of the type of appointment, who is credentialed and privileged at a specific VHA site. Note: Supervising attending and responsible attending are synonyms for supervising practitioner Text Integration Utilities (TIU) is a VistA document management application. TIU documents include but are not limited to discharge summaries, progress notes, operative reports and consult reports. 5

26 RESOURCES There are several types of organizations that influence various aspects of quality management; these include federal governmental agencies, accreditation organizations and other organizations. Some are listed below along with their web addresses Clark, Jean S., Information Management, The Compliance Guide to the JCAHO Standards, Fourth Edition, hcpro, Marblehead, MA, HIMS Management, Medical Record Review Program: Access Data Base and Data Dictionary, VA Puget Sound HIMS, Seattle, WA, Pinder, Raymond S. and Osborne, Frank H. Ph.D., Automate Ongoing Records Review, Opus Communications/HCPro Corp, Oakbrook, IL, 2002 Spath, Patrice L, Fundamentals of Health Care Quality Management, Brown- Spath & Associates, Forest Grove, OR Federal Governmental Agencies Agency for Healthcare Research and Quality ( Centers for Disease Control ( End State Renal Disease Network Organizations ( check Food and Drug Administration ( Centers for Medicare and Medicaid ( check Professional Review Organization ( Accreditation Organizations Accreditation Association for Ambulatory Health Care, Inc. ( American Accreditation Health Care Commission/URAC ( CARF: The Rehabilitation Accreditation Commission 6

27 ( Commission on Cancer ( Joint Commission on Accreditation of Healthcare Organizations ( National Committee for Quality Assurance ( Other Organizations American Society of Health-System Pharmacists ( Anesthesia Patient Safety Foundation ( Consumer Coalition for Quality Health Care ( Foundation for Accountability check ( Institute for Healthcare Improvement ( Institute for Safe Medication Practices ( National Association for Healthcare Quality ( National Quality Forum National Patient Safety Foundation ( 7