In today’s fast-paced world, we look for opportunities to stay abreast of clinical and operational information though social networking, internet searches, and print media, to name a few examples. Once information is obtained and the need to organize the information is determined, your work begins. Often we take notes when reviewing the information to assist in streamlining our thoughts. The real work begins when we need to organize these penned thoughts for dissemination. Consider the creation of a “checklist.” Now merge checklists with documentation via the electronic medical records (EMRs).
Today’s health care facilities are moving to EMRs. This electronic system has revolutionized the way data is collected, collated, and delivered at the press of a button. It links the clinical, functional, and financial information for the patient’s visit and quickly shows the work performed. The EMR tracks not only the physician’s work and assessment data, but also the work performed by all members of the wound care team. As you move forward with your EMR checklist to make sure your electronic documentation meets your clinical and operational needs, define your checklist for documentation success. It may include:
Our technology has come quite far, but documentation remains the weakest part of the chart for skin and wound care. Whether work is collected on paper or by a computer program, developing a consistent template or database for documentation is necessary to complete this process. Knowing the disease process and understanding the database are equal parts in making a whole medical record and are imperative to using the tools correctly.
“Meaningful Use” checklist
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides billions of dollars in incentives for the adoption and use of Health Information Technology by Medicare and Medicaid providers over the next 10 years. Specifically, it authorizes grants and incentives totaling an estimated $14 to $27 billion to promote the meaningful use of EMRs by providers. For these eligible providers and hospitals to receive the financial incentives set forth, they must achieve meaningful use of an EMR. The meaningful use requirements are grouped into three stages:
Stage 1 focuses on capturing data.
Stage 2 focuses on reporting health information and tracking defined clinical datasets.
Stage 3 focuses on improving performance and health outcomes.
This information is available at http://healthit.hhs.gov/portal/server.pt.
It is critical that health care providers develop the tools necessary to meet the regulatory criteria for their EMR. They also must understand the essential information and the measure of use that must be shown in Stage 1 in order to receive the incentive payments. For Stage 1, which began in 2011, the Centers for Medicare & Medicaid Services (CMS) propose 25 objectives/measures for eligible providers and 23 objectives/measures for eligible hospitals that must be met to be deemed a meaningful EMR user.
For a full explanation of the necessary criteria and components, see http://edocket.access.gpo.gov/2010/E9-31216.htm, specifically Table 1: Certification Criteria, beginning on page 2025.
Keeping your finger on the pulse of clinical and regulatory changes for documentation requirements can be a daunting task. However, this is one task that everyone needs to stay abreast of for the benefit of their facility. Designing a checklist to maintain compliance for this task may be one way to structure the oversight needed to meet expectations.
EMR wound care checklists
As detailed in the HITECH Act, the government’s research concluded that using an EMR would serve to improve patient care, increase patient safety, and simplify compliance in the U.S. health care system, as well as reduce costs in the long term, minimize errors, and increase productivity and administrative efficiency.
As the government rolls out the plan, hospitals will need to have their EMR in place and be able to send “meaningful” data to CMS and measure the actual impact on patient care.
Providers should establish an electronic assessment, documentation, clinical, and financial outcome system to capture all work and outcomes in a database. This outcome data can then be used to improve critical pathways, product formularies, contract fees with payers, and patient satisfaction. Over time, the providers with the clinically best and most cost-effective skin and wound care outcomes, the best quality assurance results, and the highest level of patient satisfaction will have the most referrals and the most profitable business.
Much of what we do in the documentation process is based on the implementation of mental and written checklists—following a series of steps that lead to a desired outcome—such as clinical and operational algorithms and pathways. For example, one of the first checklists performed in medical settings is obtaining a patient’s vital signs. Temperature, pulse, respirations, blood pressure, and now the fifth vital sign, pain (see
Chapter 2), alert the clinical team if a patient is within normal limits or if an abnormal vital sign warrants additional interventions. Completing this vital sign checklist captures fundamental information used to manage the patient.
In wound care, clinical and operational rules help maintain compliance with standards, and checklists can provide an audit tool to ensure that requirements have been followed. One example of using a checklist to help maintain compliance in the hospital involves a time out, which is one of the Joint Commission’s 2010 National Patient Safety Goals. Defined under UP.01.03.01, a time out is performed before a procedure to verify the procedure, patient, and site. To comply with this standard, one must customize the hospital’s policy and procedure, create a checklist for team members to follow, and institute and verify the checklist according to facility requirements.
For example, when reviewing the Elements of Performance for UP.01.03.01 as documented by the Joint Commission, the following checklist could be used to ensure clinical and operational accuracy in this standard. Note that the hospital determines the amount and type of documentation required.
