Documentation: Our Journey to
the EHR (so far!)
 Laura Triplett, Director, HIM
 Roseann Kilby, Clinical Informatics Analyst
 Becky Crane, Clinical Risk Manager
367 Bed Community Health System in Quincy, Illinois
2,000 Employees
240+ Physicians
Affiliates include:
- Illini Community Hospital (Critical Access Hospital in Pittsfield)
- Community Outreach Clinic
- Denman Medical Equipment
- Denman Biomedical
- Quincy Health Care Management
- Blessing Physician Services
Schools of Nursing, Radiology and Laboratory
Our EMR…
 Blessing Hospital implemented Sunrise Clinical
Manager in February of 2006
 Blessing Automated Record, or “BAR”
 Illini Community Hospital implemented Sunrise
Clinical Manager in August of 2010 (ER
documentation in 2008)
 “Mini-BAR”
 Steering committee utilized to select vendor
 Committee was multi-disciplinary
Migration Strategy
 Orders, Results, Medication Administration Record,
Nursing Worklists
 Interdisciplinary Documentation & Dictated Documents
 CPOE
 Imaging System
Legal Medical Record Policy – Maintains the timing of implementations
Interdisciplinary Documentation
 Policy and Procedure: requirements for electronic
documentation is the same as paper documentation.
 Need policy for downtime procedures
 Electronic documentation enters date/time documentation
occurs and by whom.
 “Real time” documentation is highly encouraged
 Date/time columns are created by staff that designate the
date/time the event occurred
 “WDL” - Within Defined limits-these items are defined per
observation
WDL: hover over arrow for
definition
Clinical Alerts
 Documents
 Soft Stop: Blue exclamation mark ! - indicates this
observation is mandatory for the document to be
considered complete.
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Reminds staff upon saving that these observations are necessary
for completion, allows staff to save as incomplete
 Hard Stop: Red asterisk * - indicates this observation is
mandatory for the document to be saved. Staff must
complete the observation to save the document.
 All CAPS - indicates this observation is mandatory for
the document to be considered complete.
Interdisciplinary Documentation
 Partnership with Clinical Practice Model Resource
Center (CPMRC)
 Knowledge Based Charting (KBC)-This included flow
sheets and evidenced-based guidelines for the plan of
care.
 Enter the appropriate guideline to the plan of carethis pulls in appropriate interventions, patient
education, and outcomes to the appropriate
flowsheet
Clinical Alerts
 Flow sheets
 Mandatory field is based upon completion of an
observation
Example: documentation of pulse oximetry requires the
observation for documentation for patient requirements of
oxygen
Copy Forward/Auto Enter
 Documents have the capability to copy forward
information from previous documents.
 Flow sheets have the capability to auto enter
information from previous documentation on that
flowsheet.
 Staff are instructed that this is just a tool, that the
information has to be verified with the patient that the
information remains current.
 Restrict what observations are allowed to copy
forward/auto enter.
Copy Forward – Physician Documentation
Example…..
 History and Physicals done within 30 days of admission
 Ability exists to copy forward
 Copying electronically makes it difficult to determine when the original
was created
 Recommend adding statement to copied forward document indicating
that it isn’t an original
"This document was copied forward from H&P, dated XXXX, visit XXXX.
Please see additional update for this visit, XXXX, by Dr. XXXX, the
attending of record."
Reports

Test and Validate – our strategy
1.
2.
3.
4.
5.
Create Report
Test using a fake patient
Copy production environment
Test report with real patient data
After validation, move to production environment
What you document in the system may not look the same when
printed
Downtime Processes
 Locally stored on downtime PC’s every 15 min.
 Hard copies of downtime forms
 Backload documentation
 Medications
 Orders
 Tasks
 Depending on duration of downtime
BAR Change Control Policy
 Requests for new or revised changes
 CIS Change Request Form
 Requests for changes to MLM’s* or reports
 MLM Request Form or Report Request Form
 Forwarded to care delivery redesign
 Changes made monthly unless emergent
 *Medical Logic Model
Documentation
 Legal record of care delivered
 Communication mechanism between HCP’s of IDT
 Goal: interdisciplinary, patient-focused, non-
duplicative, individualized, concise and meaningful
 Clinical Practice Guidelines used as part of POC
 Interdisciplinary Education Record
 Point of Care / Concurrent Charting
Frequency of Charting
 Systems Assessment by RN on Assessment/Interven-
tion flowsheet every 24h
 Daily between hours of 7am-3pm
 Focused Assessment / Reassessment by RN
 Between hours of 3pm-7am and as warranted by a change in condition
 Change in condition, response to care, & transfers in
level of care are documented throughout the day
 Outcome statement completed each shift by RN
 Each episode of teaching & pt/family response on
Education Outcome Record by IDT
 Additional flowsheets used as needed
Examples of Flowsheets
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Behavior/suicide
CAPD Exchange Record
CIWA
Diabetes/Glucometer
Mental Status Assessment
Neuro Assessment
NIH Stroke Scale
Nutritional Care Priority
Patient Controlled Analgesia
Respiratory Therapy
Restraint
Roto-Rest Bed
Pros & Cons of EHR
 Legible
 Concise
 Content guided by design to meet legal requirements;
much like the “T-sheets” in the ED
 Lose the story-telling aspect; fragmented
 Printed version doesn’t look like electronic version
 Check for accuracy
How to “Tell the Story”
 Outcome – Evaluation document
 14. Adult Guideline Assess/Outcome Eval [7-Jul-2011 01:37],
Visit: 1188, Nurse, Nancy (RN) [Signed: 7-Jul-2011 04:34] ,
Complete, Entered, Signed in Full, General
Summary Statement : Alert/oriented. Wearing bi-pap at night
and ET CO2 monitor. At times respirations were down to 9, held
dilaudid until in teens. States is having urinary hesitency and
feeling as if he is not empying bladder. Did bladder scan which
showed no residual. Wife in room all night with him. C/O pain
5/10 to bilateral arms and back @ worst, 2/10 following dilaudid.
No other complications.
How to “Tell the Story”
Item from pick list must be selected in order for header to
be visible on printed report.
 In this example, the nurse manually typed in
“intermittent” under grunting and “slight”
under intercostal retraction.
In the first column, the nurse manually typed in
“L” and “FiO2”. In the second column, the nurse
did not. When printed out, only the numbers
appear – see next slide
Printed flowsheet. What do the numbers indicate?
Documentation faux pas
 Words like “Accidentally” or “Somehow”
 Unit / staffing issues
 Request for 1:1
 What wasn’t done or Ordered
 Fetal heart tones not assessed this shift
 Criticizing Care of Others
 Cooling blanket improperly applied by previous shift
 Criticizing the Patient
 “Patient is obviously not in as much pain as she says she is.”
 Mention of Incident Report
 “Notified risk management, and occurrence report completed.”
Metadata
 Data about data
 Hidden attributes for individual file including name,
dates, alterations, deletion, who accessed & from
where
 Includes e-mail information: header, blind carbon
copy recipients, etc.
Litigation, Threat of Litigation,
Legal Action or Investigation
 Remove chart from normal use to preserve in original
state
 Capture electronic data ASAP
 Suspend routine destruction or disposition of records
 Preserve all relevant records regardless of form
 Importance in a lawsuit cannot be over-emphasized
 If factual, consistent, timely & complete - our best
DEFENSE
 “If it isn’t documented, it wasn’t done.”
 Document observations, action, treatment and
outcome of care YOU provided
A plaintiff’s attorney has 2 years* to thoroughly
review the chart for errors and omissions.
WDL?
 Medication order was entered, verified by pharmacy and
administered by nursing/signed off as 1500 grams of
Vancomycin…
 Patient was charged $79,181.10
Timely Documentation

Failing to document real time could result in
suspicion

E.g.: Documentation that occurred hours after pt
death
Paint A Clear Picture

Example: midnight documentation
 “pt stable, vs good, plan discharge
tomorrow.”
 3:30 am documentation of pt death.
Requests for records
 Volume
 Admission paperwork 23 pages in EHR
 One day documentation – random – 46 pages
 Largest request for records 8000+ pages ($2,500)
 Disc Format used more & more
In Summary
 Blessing’s Journey to the EMR
 A few Lessons Learned
 Some Do’s & Don’ts
 Any suggestions, comments or questions?