Documentation software cuts duplication, time
Defaults, pick lists speed up process
In the past, the staff at Integris Health-Jim Thorpe Rehabilitation Hospital in Oklahoma City used about 30 different paper forms for documentation, progress notes, and charges. They spent as much as two or three hours per week on documentation. A new computerized system, scheduled to go on line this month, has eliminated duplication and dramatically cut documentation time through defaults (automatic selection of choices), pick lists, and automatic entering of charges for therapy time.The hospital is working with Cerner Corp. in Kansas City, MO, to develop the software system, which Cerner will market. A health information systems development firm, Cerner creates electronic medical records and customizes them for hospitals.
"We saw an opportunity to work with Cerner as an Alpha partner to develop an information system. There was a lot of benefit to proceeding with it," says Kent Boevers, clinical systems analyst at Integris Health.
The hospital has been working on consolidating the documentation for six months. Initially, only the therapies will go on line with the new system. Nursing will be added later.
Ask once and document
Eliminating duplication and saving staff time was one reason the Jim Thorpe staff jumped at the opportunity to help Cerner develop the system, says hospital director Nada Dobson."Increasingly, on patient satisfaction surveys, patients have complained about asking the same questions over and over again. Now with the new form, we hope that after the first person asks that question, it will be on the chart and no one will have to ask it again," she says.
Under the old system, therapists felt they were spending a lot of time on paperwork, writing the evaluations and adding to the progress notes. In addition, since most therapists added to the charts at the end of the day, they sometimes had to wait in line to make their daily notations, Boevers points out. Now, instead of having to go to the nurses’ station and find a chart, therapists will have access through computers in the therapy offices. (The hospital also is piloting a project using radio frequency laptop computers. For details, see box, below.) Therapists will have patient information at their fingertips with the new system, he says.
No longer does each discipline collect much of the same functional and demographic information at its evaluation. Instead, the first therapist to assess a patient enters the pertinent data into the system so they can be used by all disciplines.
When a therapist is working on progress notes, the information from the last note is defaulted to the current screen so it requires only verification instead of re-entry. For instance, if a patient was on the minimal assistance level the first time a therapist documented, and it hasn’t changed, the therapist doesn’t make a change in the record.
The new documentation makes use of pick lists and numeric data entry so there is less handwritten notation. That speeds up the charting time and ensures everyone is charting the same items. Instead of writing the recommended assistive devices, for instance, the therapist chooses from a list of the most commonly used items compiled by the therapy staff. Instead of writing narratives describing the patient’s blood pressure, pulse rate, or other vital signs, the therapist simply fills in a number.
Some information entered automatically
Another time-saving step in the documentation process is the use of defaults, or automatic entering of information. This means that if a piece of information is collected by one therapist, it automatically comes up on the screen when another therapist adds to the patient record. A physical therapist may evaluate upper-arm strength, for example, and note it. Then the occupational therapist can agree or change the strength on the evaluation.To avoid discipline turf wars during the assessment process, the committee built in the ability for therapists to change the evaluation of the last person who treated the patient.
"We’re only making it more efficient if the therapist’s assessment proves to be the same as the last person’s assessment," says Cheryl Taggart, RRT, department system manager.
Managing disciplinary concerns
The therapists were concerned about relying on another discipline’s assessment until they realized they could clarify the default results.For instance, various disciplines often disagree about transferring a patient, says Pat Foote, PT, clinical director for rehab. The physical therapist may have documented that the patient can transfer with minimal assistance, but the occupational therapist may have trouble and want to document that the patient needs maximum assistance.
"In that case, we would need to look at the reason the patient was different. Maybe one therapist saw him at a time of day when he was tired, and the other saw him first thing in the morning when he was rested. The computer gives us cues to look at that we might not see with the paper process," Foote says.
In the past, the occupational therapist may not have looked at the physical therapy evaluation form to see how the PT documented certain items. Any discrepancies would not have come up until the weekly team meeting, if then, Foote explains. "If there are problems, or if one team member is doing something more efficiently than the other, we know it from the minute it happens."
Under the old system, orders were written on the chart by physicians and assigned to the therapists each morning at the report session. Now when an order is placed in the system, the computer automatically creates a task system that is trackable so the staff knows whether the work has been done and by whom.
If a patient needs to get a certain treatment twice a day, the system automatically generates two tasks. The work remains on the task list until it’s completed. If it’s not performed, there is a place to note the reason, such as the patient refused or was on an outing.
Managers can get daily reports
The system also gives managers the capability to print a daily report showing the time each therapist and discipline spends with each patient, Taggart says.In the past, each therapist filled a daily charge sheet for each patient,
documenting the time and treatment they performed. One sheet went into
the patient record and the other to the clerk in the billing resource department,
who entered the charges manually. With the new system, when the therapist
enters a treatment into the patient’s chart, the information automatically
is recorded in the financial part of the program. "No longer will there
be three different pieces of paper per patient from three different disciplines.
The auditors are happy because our charges are more accurate. We expect
a lot fewer phone calls from payers because our charges will be fully documented,"
Dobson says.
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