Where do EDs remain challenged?
An EMR does not guarantee accurate documentation
Every summer The Joint Commission issues a list of those standards hospitals find most difficult to comply with. Among those challenging standards are three that experts say most directly impact the ED:
- DC.02.03.01: The laboratory report is complete and is in the patient's clinical record.
- RC.01.01.01: The hospital maintains complete and accurate medical records for each patient.
- LS.02.01.20: The hospital maintains the integrity of the means of egress.
Compliance with the first two standards is made much easier if the ED is fortunate enough to have an electronic medical record, or EMR. "We have an EMR, and really and truly it solves a lot of problems," says Darryl Williams, RN, BSN, clinical manager of the ED at Barnes-Jewish Hospital in St. Louis, MO. "It has a direct interface with the lab. Their system talks with ours, and the results go directly into our system."
Results are flagged and posted to the record, Williams adds. "The icon turns red, yellow, and then green when it's posted," he notes. "For any critical results, they still call the doctor."
But having an EMR doesn't guarantee compliance, insists James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group in Canton, OH. "There is still an issue between the 'in' computer and guiding patient care with somebody knowing the results," Augustine says. "In the medical records for patients, it should be clear that somebody has reviewed the results and dealt with any discrepancies."
For example, he notes, when it comes to cultures, specimens are obtained in the ED, but the initial result might come back a day later. "The results can be sitting in the computer, but they do not do you any good unless a decision-maker acts on it," he says. Some computerized systems now have prompts to trigger the staff to review results of important lab work that comes back later, he says.
Diana S. Contino, RN, MBA, FAEN, senior manager of health care with Deloitte Consulting in Los Angeles, says, "The lack of compliance may be the result of policies not keeping up with technology or practice. If your organization uses an electronic system to review lab results, and staff go to this system rather than using printed copies, then define an 'active chart' as encompassing the electronic lab reports in the lab or results reporting system."
If a surveyor then pulled an active chart during a visit, the staff would be expected to describe this process and be knowledgeable of policy and procedures. "Organizations using paper charts are expected to define time frames when a chart is complete," Contino says. "In these cases, the organization needs to ensure that all final printed results are filed in the paper record."
Amend your action plan
If your ED hasn't been able to achieve this standard, there are several items that should be in your action plan, says Contino.
"First, map out the steps of this process, and identify a streamlined approach that minimizes handoffs and multiple persons being responsible for similar actions," she recommends. "One process that has been successful for some organizations is to implement automated 'final results reporting.'"
You should generate "final summary" reports from the lab system at the time that the chart is considered closed, says Contino. "These reports could even be printed on a different color paper, creating a visual queue that all labs are final and ready to file," she suggests. The outcome in this case is "one" easily identifiable report to be filed, as opposed to staff looking for multiple individual sheets.
The third step "should be the implementation of an EMR, which ultimately enhances the process of integrating the results with the patients' record, improving compliance with the standard around 'filing a laboratory result in the medical record' as well as meeting many other regulatory standards," Contino says.
Augustine says, "If you do not have an EMR, then you have to have a very sophisticated process of getting lab tests back to the emergency physicians or a responsible nurse, and make sure the results are managed appropriately."
Williams says, "If you do not have an EMR, you either have to have a paper from the lab delivered to you when resulted, or you have to take a read back; the lab calls you, and you give it." This process can be complicated, he concedes, because many people "turn numbers around" even when they read them, and handwriting these results also can cause mistakes.
Williams adds that even with an EMR, it can take quite a while to attain compliance with the second standard. "We've been working with our EMR for seven years now and customizing it, but it's just now achieved completeness," he says. Each consulting service that came down to see patients in the ED had its own consulting documentation sheet, Williams recalls.
"We eliminated that problem by creating templates in our system for them to use," he says. Another piece of paper "people chase all over the world" is the EKG, Williams says. "As soon as it is taken here, our secretary can scan it into the EMR, so our record is a complete record," he says. The accuracy of the system allows the EKGs to be read in a timely manner, including the signature of the physician who wrote the note, Williams says.
For more information on complying with standards from The Joint Commission standards:
- James Augustine, MD, FACEP, Director of Clinical Operations, Emergency Medicine Physicians, Canton, OH. Phone: (330) 493-4443. E-mail: [email protected].
- Diana S. Contino, RN, MBA, FAEN, Senior Manager of Health Care, Deloitte Consulting, Los Angeles. Phone: (949) 683-0117. E-mail: [email protected]. Web: www.deloitte.com.
- Darryl Williams, RN, BSN, ED Clinical Manager, Barnes-Jewish Hospital, St. Louis, MO. Phone: (314) 362-4349. E-mail: [email protected].
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