2021-03-10

Documentation Quality Improvement - Progress Report #1

We've posted previously about the Documentation Quality Improvement Initiative. 

Work is progressing well:

  • Two work packages have been developed, posted, presented to stakeholder groups, subjected to testing and improved after feedback:
    • Medication SmartTools - With clinical and stakeholder review/optimization complete, the new SmartLinks, Print Groups and SmartPhrases will move to the SUP pre-production environment next week for testing with a wider range of patient charts. If all goes well, the goal is to have this package moved to production by the end of the month. The Documentation Quality Improvement Workgroup has forwarded its recommendation to the Clinical Documentation Committee that the new products be approved.
    • Identity SmartTools - This work is at a similar stage of development. Subject to final SOGIE workgroup endorsement, a recommendation to ClinDoc will be made for approval to move to production. Testing and optimization has been completed. An end-of-month goal for move to PRD also applies.
  • Work progresses on two new work packages:
    • Problem-Oriented Charting Tools - With improvements to navigators, editing tools, progress note templates and text automations for streamlining summative documentation when problem-oriented charting processes are followed. Other tools (e.g., hospital course) facilitate preparation for discharge summaries. The work package will be posted next week.
    • Laboratory Data SmartTools - Text automation tools that facilitate succinct prose-friendly inclusion of laboratory data in clinical documentation are the focus of this work package, expected to be available next week.
  • Remaining Phase 1 work packages:
    • History SmartTools - Prose-friendly inclusion of medical, surgical, family and social history information in summative documentation. 
    • Objective Data SmartTools - Include those that pull vital signs, physical exam, lines and other observed information into summative documentation.
    • Transition Planning SmartTools - Representation of information key to discharge and transition planning.
    • H&P Summative Documentation - Building blocks assembled to form new H&P templates for conventional as well as problem-oriented charting.
    • Consultation Documentation - Building blocks assembled to form new consult templates for conventional as well as problem-oriented charting.
    • Discharge Documentation - Building blocks assembled to form new discharge and deceased templates for conventional as well as problem-oriented charting.
    • Transfer Summative Documentation - Building blocks assembled to form new interfacility transfer templates for conventional as well as problem-oriented charting.
    • Operation Summative Documentation - Building blocks assembled to form new operative note templates for conventional as well as problem-oriented charting.
  • Sequencing of remaining Phase 1 work packages:
    • The Documentation Quality Improvement Workgroup will consider how best to sequence remaining work packages needed to deploy new summative documentation templates, seeking to first release components most helpful to the Wave 3 launch.

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