Transcript Introduction to READ

Reviewing Effective &
Accurate Documentation:
READ Workshop
Introductory Presentation
Goals
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Understand importance of documentation
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Patient care
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“hand-offs”/covering for colleagues
health care transitions (hospital discharge)
Billing & Coding
Quality improvement & performance evaluation
Legal document
Learn key elements for various types of notes
Develop good habits NOW (at start of career)
Meet/exceed ACGME requirements
Case
You are the intern on-call on Friday and are covering for your
colleagues who recently signed-out. At 5pm, you are called
urgently by the nurse to evaluate a patient who has become less
responsive than baseline. The “primary nurse” has gone for a
break. You look to your sign-out sheet for some information on the
patient, but there is no mention of his mental status. You locate
the chart and walk into the room where you are greeted by the
patient’s extended family who has just arrived from out of state.
Upon opening the chart to review the situation, you see that the
intern has yet to put her progress note on the chart. Fortunately,
the attending note IS present…
Case
Does documentation matter?
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Direct data on patient outcomes lacking
Indirect data exists
 More
“handoffs”  more adverse events
 Improved “sign-out”  fewer adverse events
 Accurate problem list on chart  proper medications
 Discharge summary available  lower rate
readmission
Does documentation matter?
Effect on billing
 Note reflects
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 Complexity
 Time
 Expertise
Does documentation matter?
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Effect on billing
service patients  more payments
generated for hospital
 Teaching
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? Due to extensive documentation
? Due to ordering of extra tests
? Confounded by degree of medical complexity
 Teaching
attendings documentation (as pertains to
billing) worse than non-teaching attendings
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Effective documentation  viable practice
Can documentation be taught?
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Inpatient chart review & feedback  reduction in lab
ordering by 47%
Daily chart review in ED  decrease in charting errors
by 10%
Chart review in outpatient clinic  improved chart
documentation
Formal teaching program re: dictation  improved
quality of discharge summaries
Can documentation be taught?
READ Workshop developed and
implemented at IM program in CT
 Positive feedback from housestaff and
faculty
 Formal program evaluation in progress
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Ground-Rules
Constructive criticism
 Honest criticism
 No personal attacks
 Strive to protect confidentiality
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 Patient
 Author
of note
READ Workshop
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Divide into small groups (4-5 per group)
Read first note to yourself (2 min)
Assign “scribe” for your group
Discuss note using template provided (5 min)
Scribes from each small group present summary (2 min)
Scribes submit paperwork to me
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Summary template for group
Comments written directly on the note