Patient Care Assessments Chart Audits

1
Patient Care Assessments(Chart Audits)

• Faculty Assembly
• March 24, 2009

2
Overview

• Background
• New Process to be instituted for Patient Care
  Assessments (PCA) or Chart Audit
• Instructions for Chart Audits

3
Our Current Clinic QA Procedures

• Quality Care Council (QCC)
• Meets quarterly
• Includes Faculty Clinic Advisory Committee (FCAC)
  which meets monthly. Chaired by Dr Schwenk and
  currently includes Drs. Banker, Dickey, Fischer,
  Goebel, Langenwalter, Misischia, Reyes, and
  Rieken
• Considers faculty input about clinic
  procedures/policies

4
Our Current Clinic QA Procedures

• Quality Care Council (QCC)
• Includes Student Clinic Advisory Committee (SCAC)
  which also meets monthly. Chaired by Dr Schwenk
  and includes Year III and IV class presidents,
  Director of Clinic Operations, Director of Team
  Managers, and two elected representatives from
  Years III and IV
• Considers student input about clinic
  procedures/policies

5
Quality Care Council

• Reviews the following
• Accident reports
• Adverse outcomes
• After hours calls
• Patient satisfaction surveys

6
Quality Care Council

• Reviews the following (contd)
• Infection control audits
• (Please do them when asked!)
• Patient Care Assessments
• (completed by FCAC in the past)
• Patient Chart Accuracy and Completeness,
• (completed by Records office staff in the past)
• Required new process since introduction of
  axiUm
• Will be automated

7
I Need Help with a New Process

• What?
• Two Patient Care Assessments per month
• See the Patient Care Assessment form
• Who?
• In the past FCAC committee did them all (did
  total of 20/month)
• All clinical faculty with gt50 appointments and
  team leaders (will yield about
• 60 audits/month)

8
I Need Help with a New Process

• Why?
• Quality assurance to maintain our standard of
  patient care and student education
• Accreditation Standard 5-1 b
• The dental school must conduct a formal system
  of QA for the patient care program that
  demonstrates evidence of an ongoing review of a
  representative sample of patients and patient
  records to assess the appropriateness, necessity
  and quality of care provided.
• Increase of assessments performed

9
I Need Help with a New Process

• When?
• Patient names provided first Monday of each month
• Due last day of the month

10
I Need Help with a New Process

• How?
• Using axiUm
• Should take 30-60 minutes per audit
• May use any computer in the clinic
• If you want quiet/privacy, you can use the area
  outside my office or the quiet rooms next to pedo
  if unoccupied (operatories 113-116)
• Directions to follow

11
Patient Care Assessment Process(Chart Audit)

• List of patients assigned to each faculty member
  will be at front desk the first Monday of the
  month beginning in April along with chart audit
  forms and axiUm handout
• Patients will be selected at random by team
  leaders to include patients from each students
  patient pool
• Request chart from front desk staff (for
  radiographs only), all other info is in the
  electronic health record (EHR)

12
Patient Care Assessment Process (PCA)(Chart
Audit)

• Chart will be signed out to you and you are
  responsible to return it (or receive 100 point
  penalty ?)
• Charts should not be left unattended or taken out
  of the clinic for patient privacy reasons
• Return completed forms to front desk
• Audits will be due by the last day of each month

13
axiUm is more than swiping.

• Log onto a clinic computer using clinic/clinic.
• Open axiUm by double clicking on
• Swipe or enter user name and password
• Click on the rolodex icon or picture

14
(No Transcript)
15
axiUm is more than swiping..

• Enter complete patient number with no dash, e.g.
  20081456, or last name, comma, and first initial,
  eg Schwenk,D (not case sensitive)
• Then select appropriate column below name or
  chart number. Pt name will appear in bottom box
• Double click on the correct name. It will be
  highlighted in the column on the right.
• You may have to close pop ups regarding payment
  status or other information that appear.

16
(No Transcript)
17
PCA Form Question 1Appropriate history,
clinical exam and radiographs

• Click on the Electronic Health Record (EHR) Icon
  on the left.
• This will open up the patient record.
• Odontogram, perio charting and various tabs will
  be shown.

18
(No Transcript)
19
PCA Form Question 1Appropriate history,
clinical exam and radiographs

• Compare radiographs to odontogram
• To view historic odontograms, click on sundial
  and enter appropriate date.

20
(No Transcript)
21
Question 1 continued

• To view patient charting at time of treatment
  planning, enter that date.
• The odontogram that appears upon opening the
  record shows the current status.
• We will have a cheat sheet soon for the symbols
  used.

22
PCA Form Question 2Diagnosis consistent with
findings

• For treatment plan, click that tab.
• To view detailed plan, highlight the txp listed
  and click on detailed plan tab below.

23
(No Transcript)
24
PCA Form Question 2Diagnosis consistent with
findings

• To see diagnoses click on diagnosis tab at the
  bottom.

25
(No Transcript)
26
PCA Form Question 3Treatment plan consistent
with Diagnosis and patient medical status.

• Medical history, screening form and oral
  diagnosis information is under forms tab.
• Click on that tab, highlight medical history on
  the right, then click on appropriate tab in the
  middle of the screen.

27
(No Transcript)
28
PCA Form Question 4 Alternate treatment plan
given when appropriate

• Alternate treatment plans would be listed under
  treatment plan tab or notes might reveal
  alternatives offered.

29
PCA Form Question 5Chart entries appropriate

• Select Treatment History tab and click on All
  in the right hand column to view treatment
  notes.
• Look for incorrect tooth numbers, notes that are
  inappropriate or unapproved (blue), or other
  problems. For example, previous note states 4
  extracted and later note is about doing a post
  and core on 4.
• Planned and completed treatment are listed under
  the appropriate tabs on the right.

30
(No Transcript)
31
PCA Form Question 6Treatment provided in a
timely manner

• Close EHR by clicking x on upper right.

32
(No Transcript)
33
PCA Form Question 6Treatment provided in a
timely manner

• Rolodex will appear. Click on chart icon in the
  middle and patient card shows up.
• Appointments are listed and cancelations or
  failed appts are indicated.
• Contact notes will also indicate what happened
  with appts. Click on white note pad to see them.

34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
PCA Form Question 7Appropriate disposition?

• Select forms tab in EHR and look for referrals.

38
(No Transcript)
39
PCA Form Questions 8-9Appropriate case
management and treatment not compromised for
student progress

• Judgment call
• Use your overall evaluation of the case.

40

• A copy of this presentation will be posted on the
  SDM intranet at sdm.siue.edu if you wish to
  review it.
• For your reference, a few color copies of the
  screen shots will be available at the front desk
  when you check out your charts. Please return
  them when you finish your audit.
• Feel free to write any comments on the forms that
  you feel necessary to clarify issues found
• I am available to you for help

41
Questions????
42
Thanks for your help with this and for everything
else you do in the clinic!

• Deb