Discharge Documentation AuditJure Baloh, Julie Brandt, PhD, Douglas Wakefield, PhD, Becky Morton, RHIA, Kay Davis, PhD, RN, Robert Hodge, MDCenter for Health Care Quality, University of Missouri, Columbia, Missouri, USA

Discharge Documentation AuditJure Baloh, Julie Brandt, PhD, Douglas Wakefield, PhD, Becky Morton, RHIA, Kay Davis, PhD, RN, Robert Hodge, MDCenter for Health Care Quality, University of Missouri, Columbia, Missouri, USA

BackgroundThe objective of the study was to determine the compliance rates of different services at the University of Missouri Health Care regarding the discharge documentation requirements and standards set by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC).

Recommendations1. Include the provider’s contact number on the Depart Summary• Determine if contact number can be automatically added based on provider or service

2. Update the Provider Content of the Medical Record policy to reflect current practice• Review the current policy and make recommendations for revisions based on Electronic record changes, Change in procedure

for discharge documentation, TJC and CMS requirements, and Meaningful Use requirements

3. Review and analyze best practices by service• Prioritize the required data elements by importance to patient care and follow up, Determine best practices (heat map), Review

processes and specific records to find examples, Set standards for optimal documentation at discharge

4. Improvement plan developed for each service• Education for providers who document discharge information

5. Set compliance rates for each service and audit regularly• Determine what percent of records meeting each criteria is acceptable for each service

6. Standardize data elements required in each document• Review and require specific data elements that must be included in the three documents

so that it is clear to the care giver where they will find the information needed to care for the patient• Define “referring” and “primary care” physician (internal and external)• Analyze how we use current technology to make creation and compilation of the discharge information easier and more efficient

7. Review documentation requirements for outpatient surgery patients• Define discharge documentation needs for patients seen in Same Day Surgery and in Short Stay status.

Results

Requirements and StandardsADMISSION NOTE: Completed within 30 days prior/24 hours after admission, Patient’s name is correctly listed on document, Chief complaint, History of present illness (HPI), Past medical history, Past surgical history, Allergies, Medications on admission, Social history, Review of body systems, Physical examination, Pertinent lab results, Pertinent radiology results, Assessment and plan of careDISCHARGE SUMMARY: Document dictated or created within 3 days of discharge, Patient’s name is correctly listed on document, Reason for hospitalization or HPI, Hospital course and results of treatment, Pertinent lab results, Pertinent radiology results, Procedures performed, Patient’s condition and disposition at dischargePATIENT DEPART SUMMARY: Provider to complete the discharge summary (and the discharge order), Name of the attending physician, Name of the physician at discharge, Referring Physician, Primary care provider, Contains the patient’s correct name, Contains correct date and time of discharge, Document is created at the time of discharge, Final diagnosis is listed, Follow up care is listed or none indicated, Follow up appointments are listed, Medications the patient should take are listed, Patient instructions including activity and diet, Notify physician if specific symptoms appear, Physician contact information

All in all, there were 300 missing documents (27% of 1086). 78 Patient records (21% of 362) did not have any of the 3 documents

SamplesThere have been 6609 discharges from 29 services in the period from 3/1/2011 to 5/31/2011. 7 services (labeled XA - XG) were excluded from the study. From the remaining 22 services, 362 samples were randomly selected following the system on the right

service # of discharges sample size %A 1024 20 2%B 943 20 2%C 701 20 3%D 676 20 3%E 578 20 3%F 496 20 4%G 384 20 5%H 371 20 5%I 220 20 9%J 198 20 10%K 186 20 11%L 151 20 13%

M 132 20 15%N 90 10 11%O 78 10 13%P 74 10 14%R 65 10 15%S 38 10 26%T 18 18 100%U 17 17 100%V 15 15 100%Z 2 2 100%

XA 114 0 0%XB 30 0 0%XC 3 0 0%XD 2 0 0%XE 1 0 0%XF 1 0 0%XG 1 0 0%

Total 6609 362 5%

Audit ToolPt. visit# (FIN): 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013Discharge Service: A A A A A A B B B B C C CADMISSION NOTE OLD SCAN Powernote or Transcribed? p p t p t p t p t p t p tCompleted within 30 days prior/24 hrs after adm. y y y y y y y y y n y y yPatient’s name is correctly listed on document y y y y y y y y y y y y yChief Complaint y y y y y y y y y y y y yHistory of Present Illness y y y y y y y y y y y y yPast medical history y y y y y y y y y y y y yPast surgical history y y y y y y n y y y y y yAllergies y y y y y y y y y y y y yMedications on admission y y y y y n y y y y y y ySocial History y y y y y y y y y y y y yReview of Body Systems y y y y y y y y y y y y yPhysical Examination y y y y y y y y y y y y yPertinent lab results y y y y y y y y y y y y yPertinent radiology results y y y y y n y n y y y n nAssessment and plan of care y y y y y y y y y y y y yDISCHARGE SUMMARY MISS MISS Powernote or Transcribed? p p p p p p p p p p pDictated or created within 3 days of discharge y y y y y y y y y y nPatient’s name is correctly listed on document y y y y y y y y y y yReason for hospitalization or HPI y y y y y y y y y y yHospital course and results of treatment y y y y y y y y y y yPertinent lab results y y y y y y y y y y nPertinent radiology results y y y n y y y y n y nProcedures performed y y y y y y y y y y nPatient’s condition and disposition at discharge y y y y y n y y y y yPATIENT DEPART SUMMARY EXP Provider to complete the Discharge Summary y y y y y y y y y y y yAttending Physician (for the visit) y y y y y y y y y y y y

AUDIT TOOL LEGEND:p: Powernote; t: Transcribedy: Requirement/standard metn: Requirement/standard not metOLD: The document was created at another visit (within the required timeframe)SCAN: The document was a scanned formMISS: The document was missingEXP: The patient expired during the stay

AUDIT TOOL LEGEND:p: Powernote; t: Transcribedy: Requirement/standard metn: Requirement/standard not metOLD: The document was created at another visit (within the required timeframe)SCAN: The document was a scanned formMISS: The document was missingEXP: The patient expired during the stay