Here are five best practices for maintaining accurate, complete and thorough clinical documentation in your ambulatory surgery center.
1. Put a formal policy in place. Jack Egnatinsky, MD, a medical director at the Accreditation Association for Ambulatory Health Care, says complete and accurate clinical documentation is a matter of regular review and enforcement of policy. Although many ASCs implement variations of a formal policy for clinical documentation, what is crucial is that there is a formal process for review and accountability.
From: How to Ensure Complete and Accurate Clinical Record Entries: Q&A With Dr. Jack Egnatinsky of AAAHC
2. Pick a standard location for particular information on medical charts. Meg Tomlinson, administrator at Metrocrest Surgery Center in Carrollton, Texas, 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."
From: 3 Quick Tips on Consistent Clinical Documentation
3. Apply a procedure to remedy the documentation problem. To ensure proper documentation at Cape and Islands Endoscopy in Hyannis, Mass., medical charts went through two rounds of review with two nurses. Marie Boyd, administrator, says the two nurses dedicated time either throughout or at the end of each day to go through every patient chart that was handled that day.
"Whenever they had time, two of our nurses spent a part of each day going through every patient chart from that day and documenting every error," Ms. Boyd says. "Errors ranged from nurses failing to document the number of the gastroscope used during a patient's visit to lack of pre- or post-procedural calls to patients. This way, we can also identify patterns in what staff members aren't documenting properly."
From: 4 Ways to Achieve More Thorough Nursing Documentation
4. Hire one staff member to follow-through with clinical documentation. David Ott, MD, founder of Gateway Surgery Center in Phoenix, says hiring a full-time nurse helped his surgery center overcome the challenge of maintaining complete and thorough clinical records. Hiring a point-person allows for greater accountability and also allows that individual to focus and brainstorm process improvement ideas around clinical documentation.
"That nurse floats between various parts of center to make sure all documentation is being filled out," Mr. Ott says. "Fortunately, that administrator was also able to streamline the process of filling out operation notes and ensure those get done. What they have created is a short form for the operation notes, which takes less than 30 seconds to fill out. Often, nurses in the procedure room will ask us after the procedure to fill in the form and have us verify and sign it."
From: Guidance to Keep Up-to-Date Patient Records: Q&A With David Ott, Founder of Gateway Surgery Center
5. Regularly conduct chart audits. Chart audits are another method of monitoring and tracking how often physicians are complying with the standard of accurate completion of medical records. Elaine Thomas, administrator at St. Francis Mooresville (Ind.) Surgery Center, says her surgery center consults a third-party company to do the chart audits. "Since we started doing these audits, there has been a huge improvement on physician signatures in medical records," she says. "The audits have helped increase awareness with both the clinical staff and physicians."
From: 3 Ways to Ensure Completion of Medical Records
1. Put a formal policy in place. Jack Egnatinsky, MD, a medical director at the Accreditation Association for Ambulatory Health Care, says complete and accurate clinical documentation is a matter of regular review and enforcement of policy. Although many ASCs implement variations of a formal policy for clinical documentation, what is crucial is that there is a formal process for review and accountability.
From: How to Ensure Complete and Accurate Clinical Record Entries: Q&A With Dr. Jack Egnatinsky of AAAHC
2. Pick a standard location for particular information on medical charts. Meg Tomlinson, administrator at Metrocrest Surgery Center in Carrollton, Texas, 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."
From: 3 Quick Tips on Consistent Clinical Documentation
3. Apply a procedure to remedy the documentation problem. To ensure proper documentation at Cape and Islands Endoscopy in Hyannis, Mass., medical charts went through two rounds of review with two nurses. Marie Boyd, administrator, says the two nurses dedicated time either throughout or at the end of each day to go through every patient chart that was handled that day.
"Whenever they had time, two of our nurses spent a part of each day going through every patient chart from that day and documenting every error," Ms. Boyd says. "Errors ranged from nurses failing to document the number of the gastroscope used during a patient's visit to lack of pre- or post-procedural calls to patients. This way, we can also identify patterns in what staff members aren't documenting properly."
From: 4 Ways to Achieve More Thorough Nursing Documentation
4. Hire one staff member to follow-through with clinical documentation. David Ott, MD, founder of Gateway Surgery Center in Phoenix, says hiring a full-time nurse helped his surgery center overcome the challenge of maintaining complete and thorough clinical records. Hiring a point-person allows for greater accountability and also allows that individual to focus and brainstorm process improvement ideas around clinical documentation.
"That nurse floats between various parts of center to make sure all documentation is being filled out," Mr. Ott says. "Fortunately, that administrator was also able to streamline the process of filling out operation notes and ensure those get done. What they have created is a short form for the operation notes, which takes less than 30 seconds to fill out. Often, nurses in the procedure room will ask us after the procedure to fill in the form and have us verify and sign it."
From: Guidance to Keep Up-to-Date Patient Records: Q&A With David Ott, Founder of Gateway Surgery Center
5. Regularly conduct chart audits. Chart audits are another method of monitoring and tracking how often physicians are complying with the standard of accurate completion of medical records. Elaine Thomas, administrator at St. Francis Mooresville (Ind.) Surgery Center, says her surgery center consults a third-party company to do the chart audits. "Since we started doing these audits, there has been a huge improvement on physician signatures in medical records," she says. "The audits have helped increase awareness with both the clinical staff and physicians."
From: 3 Ways to Ensure Completion of Medical Records
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