Physician Documentation Improvement Project

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Physician DocumentationImprovement Project

• HIM Vital Role In ImprovingPhysician
  Documentation

Beryl Jones, MBA, RHIATina Stevens, RHIT
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Historical Background

• Project Purpose, Goal and Recommendations

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Historical Background

• Medical Staff Leadership identified a need to
  improve the quality of physician documentation.
• Physician Documentation Improvement Committee,
  comprised primarily of physicians, was
  established to champion this need.
• Project was established with primary goal to
  improve physician efficiency and documentation.

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Where To Begin

• Develop tools to support more robust, thorough
  and accurate notes.
• Establish an audit process to measure and assess
  compliance on documentation standards.
• Conduct pilot audit to determine effectiveness of
  tool.

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Pilot Findings/Recommendations

• Audit results revealed that utilization of the
  new electronic tool did not necessarily
  facilitate improved physician documentation.
• Ongoing, more in-depth audits were proposed
• But, to be done by whom

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Handoff to HIM

• Project Development Stage
• Obstacles
• Implementation

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Handoff to HIM (HIM to the Rescue)

• HIM Department was solicited by Physician
  Documentation Improvement Committee to take on
  the challenge of ongoing record audits.

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Handoff to HIM

• It was felt the project best fit within the scope
  of the departmental Regulatory Auditing Process
  the HIM Regulatory Manager was approached with
  the challenge.

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• Courage is being scared to death, but saddling
  up anyway,
• - John Wayne

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Project Development Stage

• Staffing Considerations
• Revision and Evaluation of Audit Tool
• Audit Process Established
• Database Developed (Audit and Reporting Tools)

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Project Development Stage

• Soliciting Physician Reviewers
• Physician Training

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• The greater the obstacle the more glory in
  overcoming it.
• - Moliere

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Obstacles

• Physician Reviewer Contracts
• Technical Issues

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Road Maps to Keep Us Going

• Documentation of Workflowand Processes

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Documentation of Workflow and Processes

• Policies and Procedures
• Project workflow
• Job Aids/Instructions for audit completion
• Physician Invoicing

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Outcome Reporting of Audit Results

• Reporting Process Established to include
• Reports to PDI Committee
• Hospital VPMAs
• Hospital Quality Improvement Committees

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Whats on the Horizon

• New Auditing Initiatives

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New Auditing Initiatives

• Discharge Summary Review
• Data Replication, Cloning, Cutting and Pasting

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• THE END

No Its just the beginning
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QUESTIONS