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Physician Documentation: Success with a S.O.A.P. Note Meditech Regional User Conference September 17th, 2009. Prince William Hospital. 170 Bed Birthing Center Pediatrics Emergency Surgery Diagnostic Service Mental Health-Inpatient & Outpatient Cancer Program Home Health Rehabilitation.
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Physician Documentation:Success with a S.O.A.P. NoteMeditech Regional User ConferenceSeptember 17th, 2009
Prince William Hospital • 170 Bed • Birthing Center • Pediatrics • Emergency • Surgery • Diagnostic Service • Mental Health-Inpatient & Outpatient • Cancer Program • Home Health • Rehabilitation
Respiratory Care • Sleep Disorder Center • Assisted Living • Fitness Center • Marblestone Health Center • Surgery Center • Wellness Center • Healthcote Health Center • U.S. Senate Productivity & Quality Award Winner • Press Ganey Compass Award for Outpatient Services Patient Satisfaction • Merger with Novant Health
Prince William Hospital • Admissions – 10,788 • ER Visits – 56,811 • Deliveries – 2,393 • Outpatient Visits – 145,764 • Gross Revenue – $386,500,000 • Charity Care – $10,700,000
Agenda • Why & How? • Keys to Success • Organizational Benefits
EMR Gap Analysis • What pieces of the chart are still on paper? • Physician Progress Notes – (most urgent) • Physician Orders • ER records • Anesthesia Records
Challenges with Paper Progress Notes • Handwritten, difficult to read/interpret • Charts can be difficult to find • One chart to share among several clinicians • Case Management frustration in dealing with insurance companies as a result of documentation issues • Decreased revenue due to missing/incomplete documentation
Why not traditional transcription?? • Discharge Summaries, History and Physicals, Consults, and Operative Summaries work well • Turn-around time is 4 hours • Clinicians need real time access to information for treatment plans and consulting with other physicians • Patient dissatisfaction with delay in treatment
Why Meditech PDoc?? • Physician progress notes furthers the PWHS EHR which is an organizational goal • Templates may be customized to physician preferences • Electronic documentation is available in the EHR immediately in 2 locations, “Other Reports”, and “Notes” • The EHR offers both speed and efficiency in the documentation and improvement of patient data
Progress Note Pilot Program • Began October 30, 2007 • Pediatric area of hospital (inpatient) • Small controlled environment • One on one training • Group of 20 docs • Low census area
S O A P • Free Text box • Subjective Objective • Free Text box • Vitals/ I&O’s – last recorded • Physical Exam – dropdown lists • Medications (My Data) • Labs – resulted in last 24 hr • Free Text box • Recall Text Assessment • Plan • Free Text box • Recall Text
Keys to Success • Physician Leadership & Involvement • Director of Medical Informatics - .2 FTE in IT • Physician Advisory Group – PAG • EHR Warriors • Training and Support • 1:1 On Site at Go-Live • Morning, Noon and Night
Keys to Success • Dedicated Meditech Help Line • 7 AM – 5:3 PM Monday – Friday • Remote Access to Desktop • They Know our Cell Phones !!! • Listen (they have great ideas) • Follow Through • Be Honest About What you CAN do and What you CANNOT do • Embrace the K.I.S.S Principle
With Success Expect a few Bumps • Attitude Not Aptitude • Embrace the Skeptics—Manage the Disruptive • Circles of Influence--Peer pressure will eventually come into play • PATIENCE, PATIENCE, PATIENCE!!!!!
Organization wide benefits • Increased physician satisfaction • Remote access—office, home, physician lounge • Improved information access Enhanced patient care • Ability to Encourage “Safe” Documentation
Expanding our horizons • 2008 • January – Cardiology, Pulmonary, Gastroenterology • March - Family Medicine, Internal Medicine • June – General Surgery, Nephrology, ENT • August – Oncology, Infectious Disease, Neurology • October – Allergy, Dermatology, Endocrinology, Interventional Radiology, Pain Management, Pediatric Cardiology • November – Orthopedics, Podiatry
Expanding our horizons • 2009 - Present • February – Obstetrics, Gynecology, OB Hospitalists • April – Internal Medicine Hospitalists • May – Cancer Staging Form • Under Construction • Newborn • Template Design • Admission • Discharge • Consults
Thank You Bonnie Seekford Clinical Analyst 703-369-8439 bseekfor@pwhs.org