Surgery Center Quality Improvement Study

2nd Quarter 2009

Medical Record Documentation

Date:

June 2009

Name Of Study:

Medical Record Documentation

Definition:

30% of the medical records failed the random QA audit in the 1st quarter. Nursing staff was inserviced regarding the deficiencies. 40% of the medical records failed the 2nd quarter random QA audit. This trend was alarming and prompted an additional random chart audit of 20 charts.

Standard:

100% medical records will be accurate and complete.

Data Sources:

20 randomly selected medical records from April to June 2009.

Data Findings:

70% of the medical records failed the audit. The most common deficiencies were:

Pre-op Record / Intra-op Record / Post-op
Record / Anesthesia Record / Operative Report / Physician
Orders / History and Physical
Pre-op Checklist incomplete / Missing time out time / Discharge instructions not signed by pt. / Pre-op eval not complete / No eye listed / No Date by physician / Not dated
No NPO time / No temperature / Start/ end times incorrect / Incorrect eye listed / Not noted by RN / No update note
Pre/post call not complete / No vital signs charted
No accucheck
No IV charted

Data Findings Continued:

Further analysis of the deficiencies included:

  1. Pre-op Record: When a surgical expeditor, LVN, and RN are admitting and charting on the same patient, it creates confusion as to who did what, and documentation seems more likely to be missed.
  2. Intra-op Record: Time outs are being done at the patient bedside with the surgeon, RN, and anesthesiologist but the circulating RN is not always using the chart at the time. The documentation of the time out is done after the prep, resulting in inaccurate times.
  3. Post-op Record: Charts do not always accompany the patient upon arrival to PACU. Therefore arrival vital signs are sometimes not documented on the PACU record. Signatures are missed on discharge instructions because the nurses get sidetracked answering questions and reviewing medication instructions.
  4. Anesthesia Record: A new anesthesiologist started and wasn’t aware of the complete pre-operative assessment charting. It was noted that three anesthesiologists were using their watches to document time versus the atomic clocks we have posted around the facility.
  5. Operative Report: The transcription service verified the op reports were inaccurately dictated.
  6. Physician orders: Physicians were not dating their orders. It seemed orders were not being noted by RN’s because of the familiarity with procedures and standard orders. Post operative instructions are written inside the folder containing the instruction sheets making it unnecessary for the RN to look at the physician orders.
  7. History and Physical: Physicians are not dating their history and physical at the bottom next to the signature because they were dating them at the top of the page. Day of surgery update note was not being filled out at the appropriate time because this is a new requirement and physicians are still adapting to the pre-surgical assessment requirement on the day of surgery.

Discussion:

Medical record forms could be improved to facilitate capture of complete and accurate documentation of the surgical encounter. Assuring complete documentation is more challenging with so much per diem staff. Consistent staff education is needed to keep them abreast of charting processes and problems. Physician education is needed to complete documentation.

ActionPlan:

  1. Medical record forms listed above, excluding the operative report, have been revised and all personnel have been in-serviced on new changes.
  2. Physicians have been notified of errors in operative reports that are being dictated.
  3. We have implemented a chart check, prior the RN’s leaving for the day they must audit and review all charts. We have also implemented an admission process where the surgical expeditor or LVN after completing an admission give report to an RN and the RN at that time can assess the patient and check the chart for any missing documentation.
  4. OR Circulators are instructed to use the chart during the time out, instead of before, so they can document it at the time it is occurring.
  5. OR circulators are now making sure the chart comes out of the operating room with the patient so the PACU RN can document directly on the PACU record.
  6. PACU RN’s were instructed to make signing of the discharge instructions part of the assessment process, and to have them sign prior to getting them dressed.
  7. We are now documenting on the PACU record if a post-operative accu-check is needed .
  8. Anesthesiologists were instructed to use only the atomic clocks posted around the facility to document times on the anesthesia records.
  9. Physicians were made aware of problem with not dating their history and physicals, if missed the pre-operative nurses are having the physicians fill out the original date of the history and physical while they are doing their pre-operative assessment.
  10. RN’s have been instructed to check and note physician orders upon admission prior to beginning any of the admission assessment and also immediately upon arrival into the PACU. Education was done about the difference between the instructions posted on the discharge folders vs. the instructions that are in the post operative orders.
  11. All new forms and changes to forms will be posted on the intranet weekly.
  12. Medical Record Audit Tool has been revised for more effective chart evaluation.

All changes to medial record forms as well as staff education was done in late June and early July. We will restudy in the 4th quarter to evaluate the effectiveness of these changes.

Communication:

The results of this study will be reported to the Medical Advisory Committee and the Governing Body at the July 27, 2009 meeting.

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