Improving the quality and ease of tracking invasive procedures.
Documentation of the decision-making process leading up to an outcome of procedures is essential for assessing quality of patient care, supporting reimbursement, determination of appropriate utilization, and discernment of practitioner competence. Currently, doctors document interventions conducted outside the operating room in narratives within the daily progress notes. The free-form narrative typically includes the practitioner directly involved, procedure performed, technique used and outcomes. While hospitals encourage conformity to these documentation standards, the quality and content of the narratives vary greatly by practitioner, frequently leaving significant information missing. Therefore, to improve both quality of documentation in procedure notes and ease of monitoring non-operating room procedures, we developed a multicopy standardized procedure note. The form contains lines for recording the type, location, indication, anaesthesia, findings, and complications of the procedure, plus the persons performing, supervising and undergoing the procedure. Practitioners complete the multicopy note instead of the usual narrative note. We encode all the information from the standardized note into a data base that accumulates information on all procedures done throughout the hospital. The data base is used to generate summary reports to provide feedback to residents, residency directors and practitioners on procedural proficiency. The major advantage of this system is that it simultaneously improves the quality of documentation and ease of tracking non-operating room procedures at our hospitals. In addition, the system collects the information needed for reimbursement coding, hospital quality assurance and utilization review, and practitioner and resident credentialling purposes.
Van Ruiswyk
J
J
Division of General Internal Medicine, Zablocki Veterans Administration Hospital, Milwaukee, Wisconsin 53295.
Erdmann
M
M
D002983:Clinical Competence; D003625:Data Collection; D003657:Decision Making; D004282:Documentation / Q000592:standards*; D008499:Medical Records / Q000592:standards*; D011787:Quality of Health Care