That’s Bad Form!

That’s Bad Form!Michael Ben-Aderet, Tim Cushing,

Derek Huang, Alvin Liu, John Sy, and Summer Williams

Why?• Too many forms• Forms need to be updated• Incomplete forms• Too many medical errors• Nurses paging housestaff

about orders• Housestaff unsure about

available options

Goals

• Simplify Forms• Improve Patient

Safety and Care• Improve Housestaff

Satisfaction• Meet Government

Requirements

Plan

• Review all forms that housestaff use• Highlight necessary ones that need to be

updated• Tackle those that are used the most

Old Cardiology

Form (OV1399)

From 2007

CLINICAL INFORMATION???

MEDICATIONS???

I‘M AN INTERN…HOW THE HECK SHOULD I

KNOW WHAT TEST TO ORDER???

Process

• Reviewed form with Cardiology Dept• Came up with form specifications:– Patient information • Name• Medications• HISTORY

– Test information• Cardiology WILL change test depending upon

clinical history and reason for exam

Form Cycle

Specifications

Form Design

ReviewTesting

Implementation

To be smart?

• What is a smart form?– A form that can be filled out online and/or printed

• Improve legibility• Improve accuracy of information

Now, that’s a smart form…

New Cardiology

Form (2013)

Review of Cardiology Form

• Improved transfer of information to cardiology department

• Enabled optimal testing to occur• Reduce exposure to unnecessary testing

• No longer need old EKG form – especially as outpatient, just ask clerk to enter into system and patient should present OV card to cardiology department

Medicine Admission Form (OV2428)

• Top 3 forms used by housestaff• Consistently being reviewed and updated• …but missing a lot

• A comparison of forms:– OVMC – 3 pages– Harbor – 6 pages

Specifications• Each section of the form with different

specifications depending upon the department involved… for example:

Clerks, Phlebotomy, Laboratory

Medical Administration, Patient Safety, JCHAO

Things we cannot change…

• Handwriting – PLEASE WRITE LEGIBLY

• Dosing errors – PLEASE CHECK YOUR RXs

• That the RNs will STILL page you about your patient…

Old Order Form

Basic Information – Section 1

• ICU Added – no longer a separate form• Holdover box added – nurses know who to page (especially for

hospitalist holdovers)• Admission location clear• Level of care change indication

Diagnosis and Assessment - Section 2

• Specified Isolation• What old chart???• Don’t forget our neutropenic patients!

Physician Notification – Section 3

• What the heck is a SUPO Form? – JC requirement• STANDARD VITALS!!! • Don’t forget to change them if needed!

Activity and Diet – Section 4

• Fluid restriction box

Consult and Treatment – Section 5

• Occupational Therapy• IV therapy: continuous vs fixed amount• Respiratory therapy• Chlorhexidine baths for patients on chemotherapy or with central

venous catheters (CVCs) – for nursing

Labs/Test – Section 6

• More tests, especially for ICU• No more STAT labs – abuse of STAT power• Phlebotomy Information

VTE Prophylaxis – Section 7

• Meets all government requirements• Don’t forget to select a contraindication!

Medication Reconciliation – Section 8

• Start, continue, stop?• Don’t forget hold parameters and PRNs• Home medications MUST be listed in H&P

Typical Olive View Patient…

Common Medications – Section 9

• All those and more!... Night float will thank you for that Miralax!• GI prophylaxis• Prevent therapeutic duplication• Those pesky nebs!

Insulin – Section 10

• Can’t help you there…• But at least you don’t have to write “units”!

Pain medications – Section 11

• The pen is mighty…but checkboxes are easier!• I didn’t know we had (insert pain med here)!• What is that dose of IV dilaudid again? 2 mg?!• Avoid therapeutic duplication problem

Code Status – Section 12

• Only Attendings can sign DNR/DNI orders anyway…

New Order Form

Achievement Highlights

• Eliminated ICU order form• Consistent vital signs for patient safety• Reduce use of STAT labs• Reduce therapeutic duplication• Encourage proper use of DVT and GI ppx• Eliminate confusion with med rec section• Brought in further commonly used

medications

Assessment of New Form

• Asked housestaff to fill out the old and new forms from a mock case

• Timed themselves filling out both forms• Answered 5 questions based on old and new

forms

Survey Results (n=5)

Old New

Average Time (minutes) 6.0 5.3

General Satisfaction 7.0 8.6

Error Prevention 7.8 9.0

Efficiency 7.0 8.4

Areas of Improvement 7.8 5.8

Committees

• Both forms approved by MRRC (Medical Records Review Committee)

• Admission Form must go to P&T committee to be approved (for medications) in early July

• Will uploaded to the intranet for housestaff to use after P&T committee review

Ongoing activities…

• Radiology form update• Nuclear Medicine form elimination• Insulin Form update

Acknowledgments

• Dr. Mark Richman• Dr. Mike Rotblatt• Dr. Leland Powell• Dr. Susan Stein• Dr. Katherine Yu• Dr. Dennis Yick• Dr. Nick Kamangar• Dr. Robin Waschner

• Anna Ziouzina• Laura Sarff• Karla Nungaray• Joy Mata• Lori Smith• Alma Alvarez• Jan Love• Carlos Carranza

• Clerks• Nurses• Respiratory Therapy• Housestaff