Dr Anne Duggan Acting Director Clinical Governance Mr Denis McKay, Clinical Coding Manager

1. Clinical Documentation Dr Anne Duggan Acting Director Clinical Governance Mr Denis McKay, Clinical Coding Manager HNE LHD May 2012

2. Clinical Governance – Pursuing Quality, Safety and Excellence Situation

3. Clinical Governance – Pursuing Quality, Safety and Excellence Background • What have been the consequences of poor documentation? • Safety - harm to patients • Financial - escalated costs due to extended periods of stay • (e.g. from no diagnosis(es), care plan, or investigations, etc.) • - loss of revenue to fund services and workforce • Legal - breach of legislation, litigation • Organisational – exposure of organisation and staff to harm including as “Second victim”

4. Clinical Governance – Pursuing Quality, Safety and Excellence Assessment: So how are you doing? 5 or 50?

5. Clinical Governance – Pursuing Quality, Safety and Excellence Good documentation is a cognitive activity

6. Clinical Governance – Pursuing Quality, Safety and Excellence

7. Clinical Governance – Pursuing Quality, Safety and Excellence Case 1 ED RMO 80 y.o. female Vomiting 2/7, constipation 3/7, last passed wind 1/7 ago GORD, lower abdominal tenderness, rectum empty on PR ? haematemesis, dehydration ?Gastritis /PUD Hb, EUC, AXR, cannula, PPI infusion Reg ? Haematemesis , GORD gastritis, PUD Consultant Oral PPI and fluids, scope

8. Clinical Governance – Pursuing Quality, Safety and Excellence Day 2; 0130 Nurse vomited 400 mls +50mls of “rust coloured fluid” RMO GORD, gastritis, Rx: PPI infusion, maxalon Reg Rx: Antiemetic, scope in am, repeat Hb, NBM

9. Clinical Governance – Pursuing Quality, Safety and Excellence Day 2 12 45 Endoscopy Report: “vomited a large amount of minimally blood stained fluid at the beginning of the procedure. The reason for the large volume of liquid is unclear. There is no gastric outflow obstruction” ICU Day 1 RMO notes: Dark brown vomitus ..likely haematemesis ICU Day 2 Nursing notes: Gastric aspirates very offensive in smell. BNO ICU Day 5 Nursing notes: BNO 9 days, abdo distended and firm The patient dies from respiratory failure, sepsis and an ischaemic leg

10. Clinical Governance – Pursuing Quality, Safety and Excellence Investigation Results Date Day 1 Day 2 Day 2 Time 11.39 02.30 7.47 Hb 142 139 128 Day 1 AXR “findings could represent a localized ileus or subacute obstruction” ICU AXR “dilated loops of small bowel throughout the abdomen. Gas within the ascending colon. The x ray appearances may represent a partial small bowel obstruction/ pseudo-obstruction”

11. Clinical Governance – Pursuing Quality, Safety and Excellence How prevalent is this scenario? Croskerry P. 2012

12. Clinical Governance – Pursuing Quality, Safety and Excellence Why did this occur?

13. Clinical Governance – Pursuing Quality, Safety and Excellence

14. Clinical Governance – Pursuing Quality, Safety and Excellence

15. Clinical Governance – Pursuing Quality, Safety and Excellence What does this say?

16. Cognitive Decision Making Model

17. Cognitive Decision Making

19. Clinical Governance – Pursuing Quality, Safety and Excellence

20. Clinical Governance – Pursuing Quality, Safety and Excellence How can you protect you, your colleagues and your patients from the consequences of cognitive failure?

21. Cognitive Debiasing Strategies

22. What are the essential ingredientsof a good record? Clinical records should include…… Patient’s presenting complaint, medical history (co-morbidities), medications, all allergies, smoking and alcohol history, systems review, family and social history Results of any physical examination Provisional and differential diagnosis (Final diagnosis ) Results of any investigations Clinical opinions and treatment plans Clinical Governance – Pursuing Quality, Safety and Excellence

23. Clinical Governance – Pursuing Quality, Safety and Excellence Quick quiz: Which of the following is not true? A discharge summary should: • Be used the for all inpatient episodes (including deceased, transfers, self discharges). • Be started on inpatient admission. • Include the presenting complaint (why is the patient here) • Always document the Principal/Final Diagnosis. • List all secondary diagnosis (on/due to commencement or adjustment of treatment, diagnostic procedures, increased care and monitoring) also procedural complications. • List all procedures performed. • Include discharge and follow up information (medications, out patient clinics) • Document the clinical management Electronic discharge summary CAP

24. Clinical Governance – Pursuing Quality, Safety and Excellence A word on Clinical coding: • The classification of diagnosis, procedures, other health issues by coding staff from inpatient records into alphanumeric code according to ICD10AM. • The reasons for coding include: Funding, Hospital planning, Research, Accident prevention, Teaching Reporting and Epidemiology. • Coding staff read and extract data from all of the inpatients record. They are dependant on doctors, nurses and other clinical staff documenting the patients progress from admission to discharge.

25. Clinical Governance – Pursuing Quality, Safety and Excellence A word on medical records • Patient history • Investigations and diagnostic findings • Evaluations with diagnosis • Treatment plans with diagnosis • Ward rounds with diagnosis • Diagnosis requiring intervention • Post procedural problems or complications • Operation report and dates, times and names of people involved!

26. Assessment Clinical Governance – Pursuing Quality, Safety and Excellence Where are we now? Snapshot audit 30 ED records in August 2011 Results: • 21 cases: no dates recorded • 11 cases: no provisional diagnosis • 10 cases: no plan • in 3 of the 10 cases, the clinician was unknown Action taken: • Feedback to clinicians, simple tool used • Marked improvement in September repeat audit Source: Dr A Sanchez – ED Registrar, Belmont Hospital

27. Clinical Governance – Pursuing Quality, Safety and Excellence What should we do?

28. Clinical Governance – Pursuing Quality, Safety and Excellence

29. Clinical Governance – Pursuing Quality, Safety and Excellence What should we do? • Ask “what else” • Provision diagnosis and differential diagnosis • Problem list • Procedures • Complications • Referrals • Planned investigations and referrals

30. Clinical Governance – Pursuing Quality, Safety and Excellence What should we do? Take opportunities to learn: Impact of intern involvement in RCAs in HNE Health 2011

31. Clinical Governance – Pursuing Quality, Safety and Excellence What should we do? 3. Take opportunities to improve your work environment?

32. Clinical Governance – Pursuing Quality, Safety and Excellence Take opportunities to improve your work environment? NEW in 2012 Focus groups to discuss • IT support • Environment • Work processes …to promote good documentation, good patient care and a safe working environment for all

33. Clinical Governance – Pursuing Quality, Safety and Excellence Good Medical Practice Good Medical Practice: A Code of Conduct for Doctors in Australia 4.3 Delegation, referral and handover Delegation involves you asking another health care professional to provide care on your behalf while you retain overall responsibility for the patient’s care. 4.3.2 Understanding that when you delegate, although you will not be accountable for the decisions and actions of those to whom you delegate, you remain responsible for the overall management of the patient, and for your decision to delegate. -Australian Health Practitianers’ Regulation Agency

34. Clinical Governance – Pursuing Quality, Safety and Excellence Questions?

35. Clinical Governance – Pursuing Quality, Safety and Excellence Useful references and links: http://quantiamd.com/player/vvbhxpti?courseid=97262 http://quantiamd.com/player/vvbkvywe?courseid=97262