The goal of the project has been to improve the quality of
The goal of the project has been to improve the quality of
patient records completion in terms of completeness, legibility
of clinical and care activities also recording of inpatients and
emergency room patients medical records.
Authors: Authors: Angela Greco, Quality Service, Ospedale Regionale di Locarno La Carità (EOC) e Clinica Hildebrand Centro di riabilitazione Brissago Giovanni Rabito, Quality Service, Ospedale Regionale di Locarno La Carità (EOC) e Clinica Hildebrand Centro di riabilitazione Brissago Adriana Degiorgi, Quality Department, Ente ospedaliero Cantonale (EOC)How to improve medical records completion: Locarno completion:Hospital’Hospital’s experienceAngela Greco, Ospedale Regionale di Locarno (EOC), Switzerland IntroductionIntroduction Figure 1 - Inpatient medical record evaluation chart (page 1 of 4)The goal of the project has been to improve the quality ofpatient records completion in terms of completeness, legibilityof clinical and care activities also recording of inpatients andemergency room patients medical records.Besides being a tool for the assessment and monitoring ofpatient clinical conditions, patient records play an increasinglyimportant role in clinical risk management. A complete andlegible patient record which is readily available and up to date,improves integration among health care professionals,ensures efficient delivery of patient care, and is more likely toreduce errors and patient safety risks.The patient records of the Ente Ospedaliero Cantonale (EOC)hospitals were consistently monitored in the years from 2000to 2006 as part of the quality audits run by the qualitydepartment. However, although the results of monitoring didhighlight some deficiencies in the appropriate utilization ofpatient clinical records, they did not provide the hospitalleaders with any clear direction on the areas to improve.The problem was quantified by means of quality audits and “Medication prescriptions: 1) Legibility;through the reports sent by staff and tracked by the 2) Dose; 3) Route of administration;organizational incident reporting system. 4) Frequency; 5) Goals” (hospital poster campaign) Figure 4 - Example of improvement: results of patient records review for medication management In order to analyze the results, an indicator was developed to measure the completeness of surveyed patient records, to Requirements reviewed for medication administration be tracked every four months on the basis of the results of 100% 1 1 1 1 1 4 5 2 5 3 5 audits. In order to accurately assess the effect of every 90% 9 20 single implemented improvement strategy, the indicator is 80% 5 calculated for the entire patient record as well as for the 70% 60% individual documents comprising the patient record. 50% 92 93 91 93 92 88 88 87 88 90 83 40% 68 30% Results Results 20% 10% 0% Due to ongoing monitoring, improvement actions, and to Audit july 2007 Audit december Audit april Audit july Audit july 2008 2008 2007 Audit december Audit april Audit july Audit july 2008 2008 2007 Audit december Audit april Audit july 2008 2008 2007 2007 2007 important awareness and education activity involving Date of administration Time/shift of administration Initials medical and nursing staff, a substantial improvement in the quality of patient record completion was obtained over the Complete Incomplete Missing 15 month period when the patient records review system was in place. In particular, the level of completeness of inpatient records increased from the first data point of “Traceability: clear to me, clear to all” (hospital poster campaign) 18.75% in April 2007 to the last data point of 97.85% in July 2008 as shown in figure 2. Discussion: Discussion: Figure 2 - Level of completeness of inpatient records The lesson that can be learnt from this project is that youMethods need to deploy a set of strategies requiring both top-down 97.85%In order to improve recording and entering legibility of clinical 100% and bottom-up interventions in order to improve the 87.10%and patient care activities, the Locarno Regional Hospital 90% completeness and legibility of patient clinical records. Thedeveloped a monitoring system based on a retrospective 80% 73.12% experience was so positive that we will probably repeat itanalysis of a random sample of patient records, as part of the 70% again.wider EOC pilot project on “Accreditation according to the Joint 60%Commission International quality standards”. In order to make We would like to share the strategies that allowed us to % 50% 36.56%the system fully operational and to implement the 40% achieve these results:improvement strategies, an interdisciplinary hospital 30% 18.75%committee was set up at the Locarno Hospital, with the task of 20% Clear and precise goalssupervising and coordinating all the problems concerning 10%patient records. The work done by this Committee was S1 Work method and clear standards for reference 0%sustained by ongoing and targeted awareness and supervising April 2007 July 2007 December 2007 April 2008 July 2008 Third- Third-party authority (JCI) to overcome the institutionalactivities carried out by senior physicians and head nurses on self-regarding nature The completion of single document within the medicalappropriate patient records keeping. record has also improved. In particular, by comparising data Incentive (the will to achieve JCI accreditation) from the last audit in July 2008 to those found during the Choice of charismatic individuals as part of the patientBased on patient record documentation, the Committee has audit in April 2007 (figure 3), almost all documents in the records review committeeelaborated an evaluation chart (figure 1) containing a list of patient record appear to be over 90% complete. Persistent identification of new areas for improvementrequirements regarding the entering of clinical documentation, Ongoing staff educationmore specifically 40 requirements for ER patients records and Figure 3 - Medical records general completeness Communication strategy: poster campaign on hospital strategy:72 requirements for inpatients records. wards Reassessment of the evaluation tasks assigned to theThe requirements are furthermore subdivided according to Clinical statistics intra-muros ECG 100% Patient personal data various professionals in order to eliminate redundanciesthe documentation typology and applicability criteria have been Discharge summary 80% Critical information for hospitalization Adaptation and simplification of patient recordsdefined for each of them (eg. patients with surgical procedure). High risk procedures and treatment 60% consent 40% Medical history Intensive supervision by senior physicians and headBoth “Completeness” and “Legibility” are to be evaluated for Specific surgical and invasive procedure 20% Initial nursing assessment nurseseach requirement. consent 0% Anesthesia documentation Physical examinationThe analysis has been retrospectively performed every four Anesthesia and moderate and deep Medical coursemonths by the committee for medical records reviewed on sedation consent Locarno Regional Hospital has been Written surgical report Nursing coursesamples of closed cases. Altogether, from April 2007 till July accredited by JCI - 09 May 2008 Pre-surgery assessment Medication2008, 452 inpatient medical records have been analyzed Consulting reports(equally divided in the main 10 medical disciplines of Locarno April 2007 review Jully 2008 reviewHospital) and 200 ER patients medical records. International Forum on Quality and Safety in Health Care, 20 – 23 April 2010 Nice Acropolis, Nice, France Care Acropolis, Nice,