2021-08-16

Documentation Quality Improvement - Progress Report #2

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

Work continues to progress:

  • SmartTool Building Blocks
    • All of the building blocks, or components, needed for documentation quality improvement have been examined, fixed, revised and added, using a series of previously described work packages to group different categories of SmartTools relating to:
      • Provider, Patient and Facility Identity
      • Medications
      • History, Allergies, Surgery, Devices and other structured documentation
      • Transition planning and documentation
      • Test results
      • Goals of care
      • Infection, Isolation and Immunizations
    • The new components, all now prose-friendly and complying with common style guides and data formatting standards, have been in production for a number of months. 
    • Soft-launched, the new work does not affect pre-existing documentation tools. The new elements are needed for new templates. However, they are already enjoying uptake as they solve problems previously reported.
    • The new building blocks are documented in the Builders Handbook and are increasingly promoted to builders for inclusion in all new documentation tools.
  • Problem Oriented Charting
    • Many improvements to problem-oriented charting navigators, editing tools, progress note templates and text automations are completed and stabilized.
    • Use acceptance testing continues until the end of August, when all final tweaks and enhancements will be moved to production.
  • Summative Documentation Templates
    • A phase I deliverable for the Documentation Quality Improvement initiative is a set of summative documentation templates (History & Physical, Consult, Discharge  Summary, Transfer Summary, Deceased Summary, Operative Note) that benefit from extensive stakeholder consultation about how to consistently render concise and clinically helpful summative documents. These are particularly important as they are exchanged with other health information systems, including Netcare.
    • The documentation generation tools and the associated standardized outputs have gone through extensive development, internal and external review. They are now in production for user acceptance testing by a small group of clinicians. 
    • A new release in the first week of September will include all corrections and improvements resulting from user acceptance testing. 
    • A "soft launch" in September will make the new Problem Oriented Charting, progress and summative documentation tools available together with support and training to interested clinician groups, without any requirement for uptake. 
  • Next Steps
    • Work is underway to fully integrate POC tools and innovations with the new Care Path supports emerging in Connect Care.
    • Phase II work begins to apply the POC norms and techniques to outpatient summative documentation and to the needs of different specialty groups.

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