Meg Tomlinson, administrator at Metrocrest Surgery Center in Carrollton, Texas, shares the steps her ASC took to ensure clinical documentation was being conducted in a consistent manner.
1. Pick a standard location for particular information on medical charts. Ms. Tomlinson says Metrocrest sometimes came across some inconsistencies as to where physicians would write patients' allergy information on their medical charts. In order to remedy this, the ASC established an official spot on the medical chart where physicians can fill in this critical information.
"Allergies were not always consistently placed on the same location on every form. Sometimes it would be in the upper left hand corner or some place else, but we had to put in a place where it would be consistent," she says. "So we researched a spot on the forms and highlighted it in yellow so it is more noticeable and physicians can notice it right away."
2. Educate physicians, support staff and front office staff. If your ASC has difficulty in ensuring consistently documented patient charts, educate physicians, support staff and front office staff on the importance of consistency. Education can include physicians' assistants, nurses and other clinical staff members who come into direct contact with patients' medical charts.
"Sometimes staff members don't pay close attention to detail. So they might overlook the fact that on the consent form a patient has to have surgery done on the left leg but the chart cites the right leg. When it comes time to do a time out before surgery, it makes it confusing," Ms. Tomlinson says. "We've finally gotten to the point where we did enough education and now everyone is more cautious."
3. Install a document management system. Implementing a document management system decreases the incidence of accidentally inputting incorrect information, helps clinicians capture required information that could be forgotten and ensures patient information is stored in a more consistent manner. One way Metrocrest uses its document management system is with lab results and EKGs. Ms. Tomlinson says the system allows anesthesiologists and physicians to electronically sign lab results and tests so that this responsibility isn't left on the back burner.
"We started scanning lab results and tests into our document management system and having our physicians sign electronically because previously we would put the results or tests in their mailboxes, and sometimes physicians wouldn't sign them right away because they didn't have time," she says.
Learn more about Metrocrest Surgery Center.
1. Pick a standard location for particular information on medical charts. Ms. Tomlinson says Metrocrest sometimes came across some inconsistencies as to where physicians would write patients' allergy information on their medical charts. In order to remedy this, the ASC established an official spot on the medical chart where physicians can fill in this critical information.
"Allergies were not always consistently placed on the same location on every form. Sometimes it would be in the upper left hand corner or some place else, but we had to put in a place where it would be consistent," she says. "So we researched a spot on the forms and highlighted it in yellow so it is more noticeable and physicians can notice it right away."
2. Educate physicians, support staff and front office staff. If your ASC has difficulty in ensuring consistently documented patient charts, educate physicians, support staff and front office staff on the importance of consistency. Education can include physicians' assistants, nurses and other clinical staff members who come into direct contact with patients' medical charts.
"Sometimes staff members don't pay close attention to detail. So they might overlook the fact that on the consent form a patient has to have surgery done on the left leg but the chart cites the right leg. When it comes time to do a time out before surgery, it makes it confusing," Ms. Tomlinson says. "We've finally gotten to the point where we did enough education and now everyone is more cautious."
3. Install a document management system. Implementing a document management system decreases the incidence of accidentally inputting incorrect information, helps clinicians capture required information that could be forgotten and ensures patient information is stored in a more consistent manner. One way Metrocrest uses its document management system is with lab results and EKGs. Ms. Tomlinson says the system allows anesthesiologists and physicians to electronically sign lab results and tests so that this responsibility isn't left on the back burner.
"We started scanning lab results and tests into our document management system and having our physicians sign electronically because previously we would put the results or tests in their mailboxes, and sometimes physicians wouldn't sign them right away because they didn't have time," she says.
Learn more about Metrocrest Surgery Center.