Indicator 22 Patient records meet requirements to describe and support the management of health care provided.

Transcription

1 SECTION 3: Clinical Effectiveness Process Indicator 22 Patient records meet requirements to describe and support the management of health care provided. Record Review Where do we start? Patient records must meet legal requirements to describe and support the management of health care. They must contain information that enables the identification of the patient and facilitate continuity of care. Assessment, management, progress and outcomes must be documented in a way that enables another team member to carry on with coordination, management of care, and referral to other services. General practices deliver a service that must be managed effectively to ensure that it meets the needs of patients. Integral to a good patient relationship is the keeping of a proper medical record. It is a tool for management, for communicating with other health professionals and healthcare providers, and has become an essential tool for continuity of care. The purpose of this indicator is to allow the health care provider to highlight criteria that are essential or desirable for their own practise, identify possible omissions or weaknesses in their own record keeping, and devise a plan for improvement. Lillenthal suggested commandments of medical record keeping, which, if observed, would improve practice and protect the doctor in the event of a complaint write legibly write the date and time sign legibly do not use ambiguous abbreviations do not alter notes or disguise additions do not use offensive or humorous comments check what you have written look at and deal with, and initial/date reports remember the patient may need your notes understand how the patient can get access to your notes if in doubt consult a defence organisation These commandments are applicable however to all healthcare providers with privileges to enter data in the medical records. Lillenthal C, Medical Records the eleven commandments. Journal of the Medical Defence Union, January 997. RNZCGP CORNERSTONE General Practice Accreditation Programme 20

2 Instructions Assessment of the Content of Medical Records Purpose To identify how well the practice records meet this indicator, an audit of 5 medical records per doctor/practice nurse should be completed well in advance of the assessment date. MANDATORY ACTIONS REQUIRED FOR CORNERSTONE ACCREDITATION. All doctors and nurses, including permanent locums and regular part-times, have completed an audit of fifteen (5) patient records each. 2. The audit has been conducted in the last 2 months 3. Medical records chosen show evidence of random selection Selecting patients for the record review On an agreed day, choose the notes from consecutive patients. Do not use records of the following type of patients: - Casual patients - Patients not normally seen by the doctor/practice nurse conducting the audit Retain a copy of the appointment record for the CORNERSTONE assessor to confirm the patient selection was consecutive rather than selective. 4. The practice team uses the results of the medical record review to identify quality improvement opportunities (Continuous Quality Improvement) Interpretation The practitioners shall decide whether their learning needs are best served by presenting a combined audit or individual audits by each doctor/practice nurse. A brief explanation of the reason for the choice is appropriate in the CQI report Reports should specifically address missing items considered important in the context of the practice. Keep the overall purpose of the audit in mind. This is not an assessment of an individual s competency. Reports should identify opportunities and a plan for improvement. Identify all significant issues with the records. Plan any changes made as a result of discovering problems. Identify how changes were implemented. RNZCGP CORNERSTONE General Practice Accreditation Programme 20 2

3 5. Medical records show (see criterion 22. for details) General practice in New Zealand is far from homogenous and while there are criteria that are essential for all records, other criteria may vary in their importance depending on the nature of the facility where care is being provided. Additional Information Patient consent is no longer required for the review of the medical records. Rule 5 of the Health Information Privacy Code 994 permits a health agency that holds health information to disclose the information if it: I. is required for the purposes of a professionally recognised accreditation of a health or disability service; II. is required for a professionally recognised external quality assurance programme; or III. is required for risk management assessment and the disclosure is solely to a person engaged by the agency for the purpose of assessing the agency s risk; and the information will not be published in a form which could reasonably be expected to identify any individual nor disclosed by the accreditation or quality assurance or risk management to third parties except as required by law. For individual audits: Each doctor in the practice will review a random selection of their enrolled patient medical records to assess their quality. Nurses should choose patients under their care. For practice-based audits where the type of practice does not identify a patient with a particular doctor or nurse such as student health clinics: It is important that records from each doctor and practice nurse are represented in the overall audit. The CORNERSTONE assessors should be provided with an explanation of how the selection was made. The audit will be performed by reviewing the content of the notes against the criterion measurements listed in the recording sheet Page 5. Some of these criteria will be essential for all medical records; the importance of others will vary depending on the nature of the practice. Having performed a review of records, audits should identify areas for improvement Page 5 The practice should write a brief report identifying Quality Improvement opportunities and a plan for improvement. It should specifically address every gap in legislative or essential information, as well as non-essential information, as well as non-essential items that are important in the context of the practice see page 8. An external assessment of records The CORNERSTONE General Practice Accreditation Assessment For individual doctor and practice nurse audits: The assessor will meet with each doctor/practice nurse to review the audit data, the audit results template and the record review improvement plan as well as assess two or three of the medical records per practitioner to ensure the accuracy of the self audit. Please make these documents available for the assessor to view on the day of the assessment. RNZCGP CORNERSTONE General Practice Accreditation Programme 20 3

4 For practice-based audits: The assessor will assess the doctors/practice nurses as a group to review the audit data, the audit results template and the record review improvement plan as well as assess two or three of the medical records per practitioner to ensure accuracy of the self assessment. Please make these documents available for the assessor to view on the day of the assessment. Note: Please ensure the audit data contains the patient s National Health Index (NHI) number. Every audit should be accompanied by a list of patient s names or NHI numbers. RNZCGP CORNERSTONE General Practice Accreditation Programme 20 4

5 Medical Record Review Recording Sheet Name of Doctor Name of Practice Nurse Instructions to doctors / practice nurses Record each item and total those met, not met or partially met for 5 patient records Having performed the review of records, doctors and practice nurses will identify areas of omission or weaknesses in their record keeping and devise a plan for improvement. Identify each patient reviewed with their NHI number Patient records contain sufficient information to identify the patient and document: the reason(s) for a visit, relevant examination and assessment, management, progress and outcomes Core demographic data includes: Patients name NHI number Gender Address Date of birth Contact phone no Ethnicity Registration status contact in case of emergency (ICE) Next of kin where applicable Primary languagewhere applicable Whether or not an interpreter is needed Other demographic data: occupation history Significant relationships Hapu, iwi Alternate names Medical records show: Clinically important drug reactions and other allergies (or the absence thereof) Directives by patient Problem lists are easily identifiable disease coding Past medical history Disabilities of the patient Met Part met Not met Not applicable RNZCGP CORNERSTONE General Practice Accreditation Programme 20 5

6 Met Part met Not met Not applicable English proficiency limitations Identifiable current and long-term medications(s) Reasons for changes to medication Clinical management decisions made outside consultations e.g. telephone calls Consultation records: Each entry is dated The person making the entry is identifiable The entry is understood by someone not regularly working at that practice (e.g. a locum) Consultation records support continuity of care and record: The reason for encounter Examination findings Investigations ordered Diagnosis and assessment Management/treat ment plans Health information given to patients, including notification of recalls, test results, referrals and other contacts Medications, including: drug name/dose/freque ncy/amount/time/ volume Current and long term medications Intermediate clinical outcomes Brief interventions Screening and preventative care initiatives recommended A follow-up plan End of life needs where applicable RNZCGP CORNERSTONE General Practice Accreditation Programme 20 6

7 Met Part met Not met Not applicable Name of interpreter used if applicable Risk factors are identified, including: Awareness alerts e.g. deaf, blindness, communication requirements, mental health issues Family history Current smoking status Smoking history of patients 5 and over Offer of smoking cessation where appropriate Alcohol/drug use Blood pressure Weight/height/BMI Immunisations Referral letters contain: Special considerations: interpreter needed, language, disability, transport Current problem Current medical warnings Long term medications The reason for referral Background information and history Key examination findings Current treatment Appropriate investigations and results Incoming information is filled or available electronically in the patient s medical records. This includes: Laboratory results Radiology results Other test results or health information e.g. MMSE Other health information RNZCGP CORNERSTONE General Practice Accreditation Programme 20 7

8 Met Part met Not met Not applicable Discharge and outpatients information Specialist letters Screening is up-to-date, including: Cervical smears Mammograms Cardiovascular risk assessment Diabetes screening RNZCGP CORNERSTONE General Practice Accreditation Programme 20 8

9 Audit Results An audit of 5 records Enter totals out of 5 See example page 5 Core demographic data includes: Patient name Met PM Not Met N/A NHI number Gender Address Date of birth Contact phone no Ethnicity Registration status Contact in case of emergency (ICE) Next of kin where applicable Primary language-where applicable Whether or not an interpreter is needed Other demographic data: Occupation history Significant relationships Hapu, iwi Alternate names Medical records show: Clinically important drug reactions and other allergies (or the absence thereof) Directives by patient Problem lists are easily identifiable Disease coding Past medical history Disabilities of the patient English proficiency limitations Identifiable current and long-term medications(s) Reasons for changes to medications Clinical management decisions made outside consultations e.g. telephone calls Consultation records: Each entry is dated The person making the entry is identifiable The entry can be understood by someone not regularly working at that practice (e.g. a locum) Consultation records support continuity of care and record: RNZCGP CORNERSTONE General Practice Accreditation Programme 20 9

10 Enter totals out of 5 Met PM Not Met The reason for encounter Examination findings Investigations ordered Diagnosis and assessment Management/treatment plans Health information given to patients, including notification of recalls, test results, referrals and other contacts Medications, including: drug name /dose/frequency/ amount/time/volume Current long-term medications Intermediate clinical outcomes Brief interventions Screening and preventative care initiatives recommended A follow-up plan End of life needs where applicable Name of interpreter used if applicable N/A Risk factors are identified, including: Awareness e.g. deaf, blind, communication requirements, mental health issues Family history Current smoking status Smoking history of patients 5 and over Offer of smoking cessation where appropriate Alcohol/drug use Blood pressure Weight/height/BMI Immunisations Referral letters contain: Special considerations: interpreter needed, language, disability, transport Current problem Current medical warnings Long-term medications The reason for referral Background information and history Key examination findings Current treatment Appropriate investigations and results Incoming information is filled or available electronically in the patient s medical records. This includes: Laboratory results Radiology results Other test results or health information e.g. MMSE Other health information Discharge and outpatient information RNZCGP CORNERSTONE General Practice Accreditation Programme 20 0

11 Specialist letters Screening is up-to-date, including: Enter totals out of 5 Met PM Not Met Cervical smears N/A Mammograms Cardiovascular risk assessment Diabetes screening RNZCGP CORNERSTONE General Practice Accreditation Programme 20

12 Report & Plan template Record Review comments What gaps did you discover and what changes will you make? See examples page 8 Core Demographic data Other demographic data Medical records show: Clinically important drug reactions and other allergies (or the absence thereof) Directives by patients Problem lists are easily identifiable Disease coding Past medical history Disabilities of the patient English proficiency limitations Identifiable current and long-term medication(s) Reasons for changes Clinical management decisions made outside consultation e.g. telephone calls Consultation records show: The entry is dated Person making the entry is identifiable The entry can be understood by someone not regularly working at that practice (e.g. a locum) Consultation records support continuity of care and record: The reason for encounter Examination findings Investigations ordered Diagnosis and assessment Management/treatment plans Health information given to patients, including notifications of recalls, test results, referrals and other contacts RNZCGP CORNERSTONE General Practice Accreditation Programme 20 2

13 Medications, including: drug name/dose/ frequency/amount/time/ volume Current and long-term medications Intermediate clinical outcomes Brief interventions Screening and preventative care initiatives recommended A follow up plan End of life needs where applicable Name of interpreter used If applicable Risk factors are identified, including Awareness alerts e.g. deaf, blind, communication requirements, mental health issues Family history Current smoking status Smoking history of patients 5 and over Offer of smoking cessation where appropriate Alcohol/drug use Blood pressure Weight/height/BMI Immunisations Referral letters contain: Special considerations: Interpreter needed, language, disability, transport Current problem Current medical warnings Long-term medications The reason for referral Background information and history Key examination findings Current treatment Appropriate investigations and results Incoming information is filled or available electronically in the patient s medical records. This includes: Laboratory results Radiology results RNZCGP CORNERSTONE General Practice Accreditation Programme 20 3

14 Other test results or health information e.g. MMSE Other health information Discharge and outpatient information Specialist letter Screening is up-to-date, including. Cervical smears Mammograms Cardiovascular risk assessment Diabetes screening RNZCGP CORNERSTONE General Practice Accreditation Programme 20 4

15 Example of Audit Results An audit of 5 records Totals out of 5 Met PM Not Met Core demographic data includes: N/A Patient name 5 NHI number 4 Gender 5 Address 5 Date of birth 5 Contact phone no 0 5 Ethnicity 5 Registration status 5 Contact in case of emergency (ICE) 3 2 Next of kin where applicable 0 5 Primary language-where applicable 6 9 Whether or not an interpreter is needed 2 3 Other demographic data: Occupation history Significant relationships 5 0 Hapu, iwi 3 Alternate names 0 Medical records show: Clinically important drug reactions and other allergies (or 5 the absence thereof) Directives by patient 6 9 Problem lists are easily identifiable 7 8 Disease coding 7 8 Past medical history 3 2 Disabilities of the patient 3 2 English proficiency limitations 3 2 Identifiable current and long-term medications(s) 9 6 Reasons for changes to medications 7 8 Clinical management decisions made outside consultations e.g. telephone calls Consultation records: 5 0 Each entry is dated 5 The person making the entry is identifiable 5 The entry can be understood by someone not regularly working at that practice (e.g. a locum) 5 RNZCGP CORNERSTONE General Practice Accreditation Programme 20 5

16 Consultation records support continuity of care and record: The reason for encounter Examination findings 5 Investigations ordered 8 7 Diagnosis and assessment 0 5 Management/treatment plans Health information given to patients, including 4 9 notification of recalls, test results, referrals and other contacts Medications, including: drug name /dose/frequency/ amount/time/volume 5 0 Current long-term medications Intermediate clinical outcomes 5 0 Brief interventions Screening and preventative care initiatives recommended 6 9 A follow-up plan 8 7 End of life needs where applicable 2 Name of interpreter used if applicable Risk factors are identified, including: Awareness e.g. deaf, blind, communication 2 requirements, mental health issues Family history 3 2 Current smoking status 2 Smoking history of patients 5 and over Offer of smoking cessation where appropriate 2 Alcohol/drug use 5 0 Blood pressure 6 9 Weight/height/BMI 9 6 Immunisations 6 9 Referral letters contain: Special considerations: interpreter needed, language, 2 3 disability, transport Current problem 5 0 Long-term medications 5 0 The reason for referral 5 0 Background information and history 5 0 Key examination findings 5 0 Current treatment 5 0 Appropriate investigations and results 8 7 Incoming information is filled or available electronically in the patient s medical records. This includes: Laboratory results 9 6 Radiology results 6 9 Other test results or health information e.g. MMSE 3 2 Other health information 3 2 Discharge and outpatient information 5 0 Specialist letters 5 Screening is up-to-date, including: RNZCGP CORNERSTONE General Practice Accreditation Programme 20 6

17 Cervical smears Mammograms 3 2 Cardiovascular risk assessment Diabetes screening RNZCGP CORNERSTONE General Practice Accreditation Programme 20 7

18 Example of Audit Report Record Review Improvement Plan Core Demographic data Other demographic data Medical records show: Clinically important drug reactions and other allergies (or the absence thereof) Directives by patients, Problem lists are easily identifiable One record did not have an NHI number, this is an enrolled patient and our existing process should have picked this up at the most recent consultation Five patients do not have phone number recorded. This is consistent with personal experience and possibly under-estimates our problem with phone numbers as we often receive disconnected messages for recorded phone numbers. We have unsuccessfully asked the software vendor to provide a solution that shows whether a phone number is the patient s own number or a contact number. Much of this data is poorly recorded and it is difficult to tell the difference between negatives and never asked. The practice made a commitment to improve our recording of allergy status in the problem list last year and we have progressed from a rate of 24% to 6%. The current records actually overestimate the rate (80%) because they are all recent records. Nonetheless they should therefore approach 00%. This information is not collected or Where this information is absent it is not possible to tell whether the patient has no significant problems, or whether the information has not been recorded. This does not require a process change but a reminder to reception staff to follow processes and remain vigilant is appropriate. We have met our contractual goals with the PHO, but the practice manager will ask for information on whether our NHI rate is static or increasing. This will be reported to staff in the practice s quarterly feedback. The practice manager will write to the software supplier again. We will also change our reception question from has your phone number changed? to what is your current phone number? At our next staff meeting we will assess whether some of this information can be collected when patients are reconfirming and setting priorities for this information. This will have to be done in a way that does not compromise collection of other essential information. This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. I will discuss at the next peer review group how this could be handled. The software provider is to be asked whether there is a way to record no significant problems and date this information. Disease coding This information is Disease codes are used in query builders for identifying patients with high needs. Past medical history This information is poorly recorded, needs to be improved I will discuss at the next staff meeting how this will be handled. RNZCGP CORNERSTONE General Practice Accreditation Programme 20 8

19 Disabilities of the patient This information is Discuss at next staff meeting, discuss using alert and/or read code. English proficiency limitations This information is not collected or poorly recorded Not sure where to enter this data discuss at peer group Identifiable current and long-term medication(s) This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. Reasons for changes to medication This will require ongoing vigilance. Clinical management decisions made outside consultation e.g. telephone calls We need to work on this as it was not clear if every phone conversation was recorded. The nurses record warfarin doses well. Consultation records show: I will bring the Telephone Tab to the attention of the nurses and remind the other doctors to use it when they undertake telephone consults (pretty rare, most patients would be requested to make an appointment) The entry is dated All notes had a date Person making the entry is identifiable We all enter the computer using personalised passwords. The computer identifies the entry by the initials of the provider The entry is legible and Fully computerised could be understood by someone not regularly working at that practice (e.g. a locum) Consultation records support continuity of care and record: The reason for encounter This seemed well recorded although two were a bit vague We will discuss this at our next peer meeting Examination findings Investigations ordered Diagnosis and assessment Management/treatment plans Health information given to patients, including notifications of recalls, test results, referrals and other contacts Although examination findings are recorded for all recent consultations some relevant negatives appear to be missing (e.g. not documenting that there is no rash for a febrile patient). These are clear as they are recorded in Medtech in the Outbox. This was not universally recorded but the missing data was recorded with examination findings in some trivial situations e.g. impetigo. The nurses seemed to do this really well however, notes were very brief. This was not clear from the notes. The practice has a policy on test result management however it was not clear from the notes if the patient knew how this worked. Due to present cases to the peer review group next month and will discuss the issue of missing negatives then. Discuss again with clinical team members. This is essential for continuity of care a must on the agenda at next meeting. This will be discussed at next staff meeting. We could look at abbreviations with a key for more routine information, e.g. test results. RNZCGP CORNERSTONE General Practice Accreditation Programme 20 9

20 Medications, including: drug name/dose/ frequency/amount/time/ volume Current and long-term medications Discuss with clinical team members at next staff meeting Discuss with clinical team members at next staff meeting Intermediate clinical outcomes Brief interventions Discuss with clinical team members at next staff meeting Discuss with clinical team members at next staff meeting Screening and preventative care initiatives recommended A follow up plan End of life needs where applicable Name of interpreter used If applicable Recording is scant, could be more detailed This is recorded well Not clear which patients needed an interpreter. This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. Discuss at clinical team meeting. Discuss at next staff meeting where would this information be recorded? Risk factors are identified, including: Awareness e.g. deaf, blind, communication requirements, mental issues Only one record identified an alert however this looks about right. As far as I know We already have a good system to flag disabilities like deafness. Family history Much of this data is poorly recorded At our next staff meeting we will assess whether some of this information can be collected when patients are reconfirming and setting priorities for this information. Current smoking status Use software screening tools to enter smoking status Smoking history of patients 5 and over Offer of smoking cessation where appropriate This is poorly recorded This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. Ensure brochures are available in all consult rooms, refer to nurses for appointment Alcohol/drug use This is poorly recorded This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. Blood pressure This seemed well recorded Weight/height/BMI Immunisations Referral letters contain: This seemed well recorded This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. RNZCGP CORNERSTONE General Practice Accreditation Programme 20 20

21 Special considerations: Interpreter needed, language, disability, transport Current problem This information is not collected or poorly recorded This seemed well recorded This will require ongoing vigilance but no new strategy is planned unless our current progress tails off. Current medical warnings This seemed well recorded Long-term medications Not all information is entered Need to go over this at a clinical meeting, ensure all doctors uses the wizard to insert information The reason for referral All specific information is entered Background information and history Key examination findings Current treatment The nurses seemed to do this really well however, notes were very brief. This seemed well recorded Appropriate investigations and results This seemed well recorded Incoming information is filled or available electronically in the patient s medical records. This includes: Laboratory results This was not clear from the notes. The practice has a policy on test result management however it was not clear from the notes if the patient knew how this worked. Need to go over this at a clinical meeting, ensure all doctors uses the wizard to insert information Radiology results Other test results or health information e.g. MMSE Other health information Discharge and outpatient information This was not clear from the notes. The practice has a policy on test result management however it was not clear from the notes if the patient knew how this worked. This seemed well recorded Not all information was scanned into notes This will be discussed at next staff meeting. We could look at abbreviations with a key for more routine information, e.g. test results. Ensure provider places summaries into scanning Specialist letter Most supplied specific information Need to go over this at a clinical meeting, ensure all doctors uses the wizard to insert information Screening is up-to-date, including. Results are transferred electronically Cervical smears to the patient s inbox. Mammograms Results come to practice in hard copy these are scanned into the patient s notes. Cardiovascular risk assessment We need to work on this Use Medtech CVR or BPAC CVR tools, PM to go over this with clinical staff Diabetes screening Discuss with clinical team members at next staff meeting RNZCGP CORNERSTONE General Practice Accreditation Programme 20 2