Metro North Dispelling Bad Documentation Habits in Clinicians Early Michelle Leeding – Health Information Manager Debbie Tansacha – Medical Education Officer

Metro North

Dispelling Bad Documentation Habits in Clinicians Early

Michelle Leeding – Health Information Manager

Debbie Tansacha – Medical Education Officer

Metro North Health Service District

The Journey


Setting the scene Background rationale Medical Education Unit Intern Program Lessons Learnt Where to from here?

Overview


Setting the Scene


Setting the Scene


Recommendation from Coroner’s Report

Establishment of new HIMS position Improvement of Intern Orientation

program

Background Rationale


Coroner’s Report

Black, T,J. 2008. Inquest into the cause and circumstances surrounding the death of Kenneth Maggable on 9 August 2005, Findings.

Background RationaleBackground Rationale



Health Information Management Service

Medical Education Unit



Role:Coordinates the education and training of Resident Medical Officers (Intern to PHO) within Redcliffe Hospital in line with accreditation standards and medical registration regulations

Medical Education UnitMedical Education Unit


1. Orientation / debrief

2. End of Term Audits

3. End of Term Reports / Statistics

4. End of Term Interview process

5. Mid year group results

6. End of year comparative analysis

Intern Program: Phases


Intern Program: Orientation


Mabel Smith: 79yo female

Admitted to Orthopaedic Ward

Fractured Neck of Femur

Initial pain relief in EDPMH: Ischaemic Heart Disease, Type II Diabetes

SxH: Widowed, lives alone

Allergy: Cephalexin

Case Study 1


TASK 1: Write up the admission progress notes in the chart provided

TASK 2: Write up Medication ChartTASK 3: Complete Discharge Script

Case Study 1: Tasks


…6 months later, Presentation to ED

Community acquired pneumonia complicated by her past medical history

Blood glucose levels unstable

Minor dehydration Impaired renal function

Case Study 2


TASK 1: Find and review Resus Plan in Chart provided. Identify key elements to consider

TASK 2: Write up Insulin Order

TASK 3: Complete a Death Certificate

Case Study 2: Tasks


Audit Results Clinical Coding Feedback from

Interns

Orientation: Debrief


End of Term Audit & Reports


End of Term Interview processEnd of Term Interviews


Mid Year Group Results


Annual Report Group results Comparison with overall hospital

documentation results

Awards Best overall result

End of Year Analysis


Intern’s Perspective


Lessons LearntLessons Learnt


Where to from here?

Documents

Metro North Dispelling Bad Documentation Habits in Clinicians Early Michelle Leeding – Health Information Manager Debbie Tansacha – Medical Education Officer