1 / 11

VANDERBILT HOME CARE SERVICES

VANDERBILT HOME CARE SERVICES. “ Quality Of Documentation Of Rehab Staff Over The Course Of Patient Treatment”. Purpose. To determine which Key Function Indicators are most frequently missed during clinical documentation. Goal.

imala
Download Presentation

VANDERBILT HOME CARE SERVICES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. VANDERBILT HOME CARE SERVICES “Quality Of Documentation Of Rehab Staff Over The Course Of Patient Treatment”

  2. Purpose • To determine which Key Function Indicators are most frequently missed during clinical documentation

  3. Goal • To improve rehab documentation of all staff from evaluation to discharge of patients in order to meet agency standard of 100% on Key Functions on CQI monitor

  4. Procedure/Process/Methodology • Chart audits of Key Functions were performed from April, 2007, through June, 2008 • Data was organized by type of clinician (OT, PT, ST), by division (pediatrics, adult), and by whether the staff was salaried or pay-per-visit • Data results were reviewed with administrators • Current learning tool for documentation was reviewed and updated

  5. Procedure/Process/Methodology 5) New staff was instructed in proper documentation needed to fulfill Key Functions on CQI monitor 6) Proposed – Distribute new learning tool to all staff and instruct in how to document properly for Key Functions on CQI monitor (This process was never completed due to CQI leader’s agency position was eliminated prior to completion of CQI project)

  6. Procedure/Process/Methodology • Proposed – Perform additional chart audits by March, 2009, to document improvement in staff documentation in order to meet agency standard of 100% on Key Functions of CQI monitor ((This process was never completed due to CQI leader’s agency position was eliminated prior to completion of CQI project)

  7. Assessment Therapist’s most frequently omitted items on Key Functions on CQI monitor: • Patient/Caregiver understands and agrees to participate in Plan of Care (14 times) • If pain is present, plan for management is established (8 times) • Discharge planning is initiated on admission (5 times) • Pain is assessed with every visit (4 times)

  8. Assessment Percentage of charts completed properly by agency rehab disciplines (OT, PT, ST), comparing salaried and pay-per-visit: Agency (all disciplines) – 95.7% Agency (all salaried) - 98.5% Agency (all pay-per-visit) – 94.5%

  9. Assessment Percentage of charts completed properly by agency rehab staff, comparing disciplines (OT, PT, ST): • Physical Therapy (salaried) - 98.5% • Physical Therapy (pay-per-visit) – 93.6% • Occupational Therapy (pay-per-visit) – 97.5% • Speech Therapy (pay-per-visit) – 92.5%

  10. Assessment Percentage of charts completed properly by agency rehab staff, comparing pediatric and adult staff: • Physical Therapy (adult) - 95.9% • Physical Therapy (peds) - 98.9% • Occupational Therapy (peds) – 97.5 • Speech Therapy (adult) – 92.5%

  11. Recommendations • Finish updating documentation learning tool • Distribute updated documentation learning tool to all staff and instruct in changes • Using updated documentation learning tool, instruct each new staff on documentation needed in order to meet agency standard of 100% on Key Functions on CQI monitor • After using updated documentation learning tool, complete 3 months of chart audits to measure the tool’s effectiveness

More Related