2021-09-16

Documentation Quality Improvement - Progress Report #3

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

After a few months of testing among early-adopters, a number of fixes and improvements are released mid-September in a continued "soft launch" that makes new tools available to interested users without affecting pre-existing tools or workflows:

  • SmartTool Building Blocks
    • Some documentation building blocks (SmartLinks, SmartPhrases, SmartLists, etc.) used in problem-oriented charting tools have been further improved. In some cases, ways have been found to better format for more skimmable reports. In other cases, options have been added to make it easier for users to bypass documentation components that they do not need for a particular note. The end result is fewer clicks for the user and a faster workflow.
    • The new components, all prose-friendly and complying with common style guides and data formatting standards, are being listed in the Connect Care Manual for the benefit of users wanting to include them in personalized templates or text blocks. 
  • Data-Documentation Integration
    • Enhanced documentation templates and charting views now include more "precision links" to relevant charting tools. If, for example, one selects frailty assessment as part of transition-planning documentation, a link "hot spot" appears in the document draft to facilitate instant access to a pop-up for entering or updating frailty score information. 
  • Adaptable Charting Elements
    • More work has been done to support a "build-your-own-journey" approach to problem-oriented documentation. Templates include optional SmartLists that allow users to pull in the types of information, and level of detail, appropriate to their charting purpose. 
  • Dynamic Charting Elements
    • We have added and tested an ability to display customized summative documentation content when specific patient (e.g., age, health problems), provider (e.g., specialty) or context (e.g., outpatient, inpatient, emergency) conditions are met. The first application of this ability brings some disease management content into discharge summaries when patients are on specific care paths.
  • Hospital Course
    • An improved optional starter text block for the hospital course is implemented with SmartForm support allowing the same data elements to be pulled into appropriate parts of  consult, discharge, operative and transfer summaries.
  • Problem Overviews
    • Support is added for using standardized problem overview elements, with SmartForm support for reusing the data in other documentation objects.
    • Support is added for dynamic problem overviews that bring unique content in for common chronic illnesses.
  • COVID-19 Status
    • A new COVID-19 status text block is included in many templates, bringing swab, serology, immunization and self-reported immunization information together in one place.
  • Sidebar Support
    • The problem-oriented charting sidebar for inpatients has been improved to include more hotspots for rapid updating of structured chart data.
  • Summative Documentation Templates - Instant Access
    • A phase I deliverable for the DQI initiative is a set of summative documentation templates (History & PhysicalConsultDischarge  SummaryTransfer SummaryDeceased Summary, Operative Note).
    • Previously, users would need to know the correct SmartPhrase or SmartText name to use these templates to initiate a summative document. Now, the document types, preloaded with the intended templates, can be initiated with a mouse click from the POC sidebar or the general inpatient sidebar.
  • Next Steps
    • These and other enhancements are implemented in the second week of September, with DQI soft-launch proceeding in the third week.

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