Stephanie, a clinical documentation improvement (CDI) professional, has been growing frustrated with the lack of consistency in patient chart mai

SCENARIO 1

Stephanie, a clinical documentation improvement (CDI) professional, has been growing frustrated with the lack of consistency in patient chart maintenance on the units of care. While most documentation is captured and housed electronically, there are also several items that are still maintained as handwritten documentation. This documentation is housed in plastic binders and stored at nursing stations while the patient is receiving care in the hospital. Each of the health care units stores the documents in a different order within the folder. This causes the clinician to waste time by unnecessarily scouring through the documentation. Eventually, all remaining handwritten documentation would be transitioned to electronic storage in a phased approach. However, in the meantime, Stephanie thought keeping the handwritten documents in a consistent order would reduce time spent searching for documents and improve patient care.

Stephanie spends much of her time looking at documentation and she tries to note any issues that may be of concern to the organization. She has noted opportunities for reducing dangerous or “do not use” abbreviations. Auditing documentation for abbreviation issues isn’t one of Stephanie’s responsibilities; however, she understands how important this is and wants to be sure the hospital is improving on all aspects of documentation. Stephanie relays her findings to the quality department which also tracks the misuse of abbreviations.

Another key item of concern for Stephanie is that on one of the fifth-floor units, she consistently finds incident reports filed in patient charts. Stephanie remembers being advised multiple times that incident reports should never be filed in patient charts. Staff should not document that an incident report has been completed and should also not refer to the incident report when charting. The incident report should be filed with the risk management office, and it is considered a secondary source of patient information.

Stephanie speaks with her manager, Lori, to alert her to the improper filing of incident reports. Lori agrees that Stephanie’s findings should be addressed with Maurice, the Director of Neurological Services. Lori schedules a meeting with Maurice and provides an overview of the concern. Maurice is very grateful that Lori alerted him to the issue. He informs Lori that he will be holding an in-service to ensure the staff understands incident reports, how they are utilized, and the proper ways to document them. Maurice also asks Lori to thank her staff for finding this as he had not located any issues when he completed his last quarterly audit on documentation.

1. Why did Stephanie think it was important to share her findings about the incident reports with her manager?

 2. Why did Stephanie feel it was necessary to relay her findings about the use of "do not use" abbreviations to the quality department, even though looking for these abbreviations was not her responsibility?

3. If you were Stephanie, how would you ensure the consistency in the order of the records?
 

SCENARIO 2

The physicians at Aubreyville Regional Hospital were growing increasingly frustrated with the lack of access to the historical handwritten documentation detailing their patients’ previous encounters. The facility is a 214-bed hospital and often attracts world-renowned physicians due to its excellent reputation. It is a smaller facility and unfortunately has become somewhat behind in transitioning to emerging technology to improve documentation efforts. Tammy, Aubreyville Regional Hospital’s Health Information Management (HIM) Director, was new to her role but was aware of these issues when she accepted her position.

During the monthly leadership council, Dr. Jones expressed her concern over several inefficiencies when attempting to retrieve historical information on her patients. She indicated that she had no issues locating labs, radiology, patient demographics and dictated reports for the current visit as they were housed in the electronic medical record (EMR) utilized at Aubreyville Regional Hospital. These documents were electronically interfaced to the EMR and were available to be quickly referenced. However, Dr. Jones noted such handwritten documents – progress notes, physician orders, and other graphic flowsheets were retrievable only by contacting the HIM department. The HIM department was not staffed 24/7 and this often resulted in delays to obtaining paper documentation. As Dr. Jones was presenting her concern, other physicians began to express their displeasure in this process as well.

Kate, Aubreyville Regional Hospital’s Chief Operating Officer (COO) quickly determined that this concern was valid. After listening to the discussion, Kate knew that there needed to be an improved way to connect the handwritten documentation to the electronically interfaced information. Kate met with Tammy to discuss the options for removing this physician satisfaction barrier and potential patient care inhibitor. Tammy informed Kate that the concept of a hybrid record was something that should be considered. In this environment, HIM would perform document imaging processes on the handwritten documentation. This would allow the handwritten information to flow to the patient chart and connect with the existing electronically fed documents.

Document imaging is a process that is widely used throughout HIM departments. This approach helps to bridge the gap between a fully paper-based hospital to one that is fully electronic. Document imaging requires the HIM teams to prep, scan, index, and quality control all handwritten documents that are retrieved upon patient discharge or visit. While it sounds like a very tedious task, the steps naturally replace similar processes in paper-based environments. Tammy’s team would see their current roles transitioning to meet the new needs of an electronic world.

Tammy and Kate discussed potential vendors and software options. Once the top contenders were chosen, they took the proposed change to various committees in an attempt to obtain physician and other integral leader support. An in-depth financial analysis was also performed to determine the benefits of a hybrid record. The response was overwhelmingly positive. Tammy knew that a final hurdle she needed to overcome was to discuss the change with her staff. Her staff seemed excited yet nervous to take on the document imaging challenge. However, after reviewing all of the pros/cons, most of the HIM staff understood that this was the best route for improving patient care, physician satisfaction, as well as staff productivity. Tammy did notice that four of her key staff members immediately submitted resignation letters upon learning about the upcoming major process change.

Because employee satisfaction and retention are so important, Tammy decided to conduct one-on-one meetings with the newly created document imaging team members. After further reviewing and ensuring each team member that this change was a positive and much needed improvement, Tammy was able to satisfy each of the staff’s concerns. Six weeks later, Tammy reviewed the progress with Kate. Kate was very grateful that Tammy was proactive in addressing the staff’s concerns so that HIM employee turnover would remain low.

1. Why do you think Dr. Jones was so passionate about the topic of retrieving historical information on her patients?

2. Tammy encountered a staffing issue when introducing a new concept on processing medical records – why do you think the staff became concerned with this change?

3. Kate, Chief Operating Officer (COO) and Tammy, Health Information Management Director worked together to determine possible options to solve the concerns of the physicians. Why do you think Kate consulted Tammy immediately about this topic?