Physician Documentation Improvement Project

1. Physician DocumentationImprovement Project HIM Vital Role In ImprovingPhysician Documentation Beryl Jones, MBA, RHIATina Stevens, RHIT

2. Historical Background Project Purpose, Goal and Recommendations

3. 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.

4. 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.

5. 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

6. Handoff to HIM Project Development Stage Obstacles Implementation

7. 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.

8. 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.

9. “Courage is being scared to death, but saddling up anyway,” - John Wayne

10. Project Development Stage • Staffing Considerations • Revision and Evaluation of Audit Tool • Audit Process Established • Database Developed (Audit and Reporting Tools)

11. Project Development Stage • Soliciting Physician Reviewers • Physician Training

12. “The greater the obstacle the more glory in overcoming it.” - Moliere

13. Obstacles • Physician Reviewer Contracts • Technical Issues

15. Road Maps to Keep Us Going Documentation of Workflowand Processes

16. Documentation of Workflow and Processes • Policies and Procedures • Project workflow • Job Aids/Instructions for audit completion • Physician Invoicing

17. Outcome Reporting of Audit Results • Reporting Process Established to include: • Reports to PDI Committee • Hospital VPMAs • Hospital Quality Improvement Committees

18. What’s on the Horizon… New Auditing Initiatives

19. New Auditing Initiatives • Discharge Summary Review • Data Replication, Cloning, Cutting and Pasting

20. THE END No… It’s just the beginning…

21. QUESTIONS