ANNUAL REPORT (June – May, 2008-2009) CLINICAL DOCUMENTATION COMMITTEE The following is a summary of the major activities of the Clinical Documentation Committee during June through May, 2008-2009. This report is prepared to communicate the activities of the Committee to the Medical Staff and to meet The Joint Commission requirements. MEMBERSHIP: The Committee initiated and completed the year with the following members: Donald Spencer, MD, Chairman (Family Medicine); Robert Berger, MD (Medicine); Rowell Daniels (Pharmacy); Lynn Fordham, M.D. (Radiology); Lav Goyal, MD (Radiation Oncology); Catherine Hammett-Stabler, PhD (Pathology); Michael Hill, MD (Psychiatry); Paul Lachiewicz, MD (Orthopedics); Larry Mandelkehr (CQI); Douglas Mann, MD (Neurology); Tracy Parham (ISD); Alden Parsons, MD (Housestaff-Surgery); Joni Perry, RHIA (MIM); Melissa Rajappan, RHIA (MIM); Austin Rose, MD (ENT) and Robert Tomsick, MD (Dermatology). Sherry Brown, RN (Nursing Practice, Education & Research); Lukas Castillo, RHIA (MIM); John Hart (Audit & Compliance); Trista Pfeiffenberger (Pharmacy) and Emil Usinger (MIM). During the year, the following members were added to the Committee: Ben Gilbert, Legal; Chris Ellington, Administration; Pat Yee, Nursing; Laura Harmon, Accreditation, Tim Sadiq, MD, Surgery. The following departments currently do not have representatives on the Committee: Anesthesiology, Dental, Emergency Department, OB/GYN, Ophthalmology, UNC P&A, and House Staff Representative for Medicine. The Department of Orthopedics representative is also leaving UNC HCS. ACTION TAKEN: 1) CDC Topical Focus Plan: The Committee continues to work through the Topical Focus Plan over the year to address key issues. Issues from the Topical Focus Plan that were addressed are a) Phone Messaging Usage by Physicians (Clinician to Clinician electronic communication). 2) Phone Messaging Usage by Physicians: The Committee discussed ways to improve the quality of the Medical record documentation and one of the areas that needed attention was the use of phone messaging. There were a lot of complaints that there was not a forwarding function for phone messaging, so additional functions were added. The Phone messages become a part of the medical record once they have been finalized, so another user cannot view the messages until this has taken place. Phone messaging is now being used for more critical things and not just messages.
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3) Physician Documentation/Coding Queries Proposal: The Committee discussed Physician Documentation/Coding Queries and discussed that there was a big increase in the number of coding queries. It was suspected that the increase was due to MS-DRG’s and POA implementation and as a result the response rate had dropped drastically. The three Physician Advisors: Dr. Peppercorn, Dr. Barnhouse and Dr. Dupree met with Dr. Goldstein and discussed the physician documentation and the training that will take place for the residents on MSDRG’s and POA. It was strongly recommended by the Physician Advisors that unanswered physician queries be documented as a deficiency and should bear some weight. The CDC approved the recommendation and it was sent to the MSEC as a Consent Agenda item. 4) Ongoing Medical Record Reviews: A number of ongoing medical record reviews were performed monthly and results were reported to the Committee for appropriate action. Reviews included Inpatient Documentation; Prohibited abbreviations on Surgery/Procedure Consent Forms; Review on Organ Tissue and Donation; Review on Provisional Anatomic Diagnosis and Final Autopsy Reports; Brief OP Note; History & Physical Surgical Services; EMTALA Form Audit; H&P Review for Burn Unit; Verbal Orders; Restraint Audit, and Patient Discharge Information Review. The findings of the reviews and requests for plans of action to address areas out of compliance were communicated to the appropriate departments and individuals including recommendations for Executive Committee action if applicable. 5) CPOE Final Report to WebCIS: It was discussed by the Committee that CPOE orders are not easily retrievable online as they are manually scanned. A CPOE report will be created upon discharge and sent to WebCIS at discharge so that it can be viewed without MIM manually scanning the orders. The permanent solution would be that the CPOE orders would be stored online, but this is still a couple of years away. With input from CDC on formatting, etc. this was implemented which has eliminated manual scanning of many pages of orders. 6) Forms Review: The Committee, utilizing a pre-Committee review process, approved 45 new paper forms and 39 revised paper forms and one WebCIS template, for official use in the medical record. 7) Monthly Undictated Operative Reports Top Ten List: The Committee continued the review of the top 10 offenders for undictated operative reports. The Committee identified 12 instances where attending physicians were referred to the credentialing committee who appeared on the top 10 list for 3 rolling consecutive months and 1 instance where residents were referred to the Graduate Medical Education Committee. 8) Signing of Verbal Orders within 48 hours: The Committee continues to review electronically. The Committee will continue to monitor this in order to remain within compliance. Ongoing review shows less than 1% of non-compliance.
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9) Medical Staff Privacy Violations: The Committee continues to be responsible for reviewing corrective action letters provided to the Medical Staff as a result of privacy violations. The Committee did not have any physicians that received letters for violations for approval to be reported to the Credentials Committee for consideration in the reappointment process.
10) Medical Record Documentation for Determining Level of Care: The Committee discussed documentation in the medical record for determining level of care. We are now under a plan of corrective action as a result of an audit that was performed by CAHABA. The Care Coordinators are now holding cases in an OP or Observation State until the admitting team documentation was updated. However, this is delaying determination because of delays in getting H&P’s documented. As a result, the Committee has performed focused audits on completion of H&P’s. 11) WebCIS Prenatal Documentation Demo: The Committee discussed the new design for the documentation for prenatal care and the new prototype that was completed. The idea is to have a continuum of care from Prenatal to Neonatal. The Committee provided input to various screens and output. 12) Recommendation to drop 3 month OP Report Trend from top 10 to top 5: The Committee discussed changing the criteria in order to reduce the list of top offenders. The Committee discussed that there was some improvement in the undictated op report. It was decided to look at the criteria and see if it should be revised. The Committee approved to change the undictated op report trend criteria to any physician that has 5 or more undictated delinquent charts. However, instead of reducing the list, it increased the number. The Committee decided to use the criteria of 10 charts and 50 days for a couple of months and then further discuss the issue. After making various tweaks to the report, it was finally decided to trend the top 10 and audit the report to remove physicians when they have 5 or fewer charts or 10 or fewer days. 13) Update to Policy/Procedure for Authorization to Document in the Medical Record: As a requirement by The Joint Commission we are required to produce a document that tells who is authorized to document in the medical record. The committee approved adding Orthodist to the list since they are now documenting and billing.
14) WebCIS Monthly Report: Dr. Berger/Tracy Parham continue to provide reports each month on the status of the development of the electronic record and request input provided by the Committee members and address issues related to regulatory requirements, etc. as necessary.
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15) Departmental Report and Key Indicators:The Committee continued to review the key indicators presented by the MIM Department to assure compliance with The Joint Commission standards and hospital policy for turnaround times including loose material received, scanning metrics, undictated operative reports, total delinquent records, and transcription turnaround times. 16) Documentation Improvement Program: MIM department Documentation Specialists gave an overview of the Documentation Improvement Program activities at a couple of meetings. The program will improve the quality of care, real time feedback and provides resources and education. It also reduces retrospective queries and provides quicker billing of claims. The CDC saw the numerous benefits to improving documentation for reimbursement, quality of care and appropriate severity and mortality and will continue to support the department’s efforts. 17) Recovery Audit Contractors (RAC) Update: The Committee discussed how UNC HCS is preparing for RACs and the things that are being done to prepare. The RAC workgroup is reviewing software packages for RAC tracking tools. The Documentation Improvement Program and Concurrent Documentation Reviews are being revitalized that will also help with these audits. Analysis and internal audits are being performed for coding and documentation issues, medical necessity and level of care issues. 18) Data Warehouse Update and Data Use Agreement: Dr. Spencer did a demo of the new Data Warehouse System for purposes of pulling data for Research and Quality Improvement. He presented the Date Use Agreement and the HD974 that has been in use for Researchers to access info. He has asked the Committee for input.
ITEMS OUTSTANDING: 1) Electronic Medical Record/WebCIS Reports: The Committee will continue to provide feedback to Dr. Berger and Ms. Parham to enhance the electronic medical record. In addition, the CDC will continue to assess the scope of support and process by which the Committee will provide when requests for functional changes to the electronic record are submitted. The Committee will continue to evolve surrounding the scope of responsibility which may include a more focused review of clinical content that also involves consideration for workflows and the processes. 2) Ongoing Medical Record Reviews: The ongoing medical record reviews will continue to be performed on at least a quarterly basis to identify areas of documentation improvement needs and to meet The Joint Commission requirements. Focused areas that continue to need periodic reviews include
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restraints and seclusion documentation which are standards now in the Record of Care, Treatment, and Services Standards. 3) Documentation Improvement initiatives: With the demands being placed upon electronic medical records and more thorough documentation and the upcoming RAC’s, the Committee will continue to provide input and be a resource for ideas to improve and enhance the Documentation Improvement Program.
4) Electronic WebCIS Templates and Forms: The Committee continues to work through the processes for reviewing and approving electronic medical record templates by reducing paper form requests and will work through the forms subcommittee represented by ISD. 5) Committee Membership: The Committee has requested assistance from the Medical Staff Executive Committee to recommend physicians to represent those departments that currently are not represented on the CDC Committee. The representatives needed are listed above. With the evolving use of the electronic medical record and its impact on documentation as well as the external regulatory requirements that demand higher standards for medical record documentation, the need to have a representative from each clinical department becomes more imperative. 6) Administrative Reports on Unanswered Phone Messages: The Committee reviewed unanswered phone messages. There is currently nothing mandating phone messages be viewed and there is no priority to them. The phone messages are not visible in the record until they are finalized. The Committee considered sending letters to physicians identified as having a high number of unanswered messages, but have not finalized an approach at this time.
Donald Spencer, M.D., MBA, Chairman Medical Information Management Committee June 4, 2008
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