Paper
Thursday, 20 July 2006
This presentation is part of : Outcomes Measurement
Correct Documentation: The Axis
Michael Brown, BSN, RN, CCA, Cardiac catheterization laboratories, The Methodist Hospital, Houston, TX, USA
Learning Objective #1: Describe a successful implementation of a process improvement project based on evidence-based practice.
Learning Objective #2: Discuss tools and strategy used that lead to correct patient care documentation.
Documentation of patient care functions much like that of a spoke in a wheel: providing support and a common point of reference for the whole.  Evidence supports that the quality of data recorded is an important as the quality of care given to patients. Correct documentation provides a vital link between caregiver and patient. Correspondingly; the significance of this issue is far reaching. One only has to consider the ramifications that inaccurate or incomplete data could have on financial considerations, legal questions, and patient safety. Study showed that the indications for the procedures and incomplete descriptions of the procedure were common deficiencies found in audited cases.  CMS found that in 2004 payment errors resulted from incomplete documentation of care given and need for medical necessity. Office of Inspector General has focused on accurate, complete, timeliness and “date and legible identity of the observer,” of the signatures. Consequently, poor documentation can result in inaccurate coding that can affect dollars assigned to DRG’S. 
An area of process improvement opportunity was identified in the cardiac catheterization unit to identify baseline procedure documentation accuracy and identify potential revenue loss. Educational in-services, two tools was developed, a double-checking strategy was implemented. After three months of implementing process improvement initiatives, potential revenue loss was decreased from $85,000.00 to $25,000.00. This presentation will show that proper documentation not only impacts the financial health of the organization but most importantly promote patient safety.

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See more of The 17th International Nursing Research Congress Focusing on Evidence-Based Practice (19-22 July 2006)