The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts

DEVELOPMENT AND IMPLEMENTATION OF AN ELECTRONIC MEDICAL RECORD CHART AUDIT PROCESS

Russell E. Graham, Michael Bernstein, Roberta Melton, Adrianne Gentry, Stanley Rhone; Respiratory Care, Memorial Hermann - Texas Medical Center, Houston, TX

Background: There are multiple Joint Commission standards in place that necessitate an ongoing chart audit process to ensure compliance (RC.01.04.01, RC.02.01.01, PC.01.02.10, PC.01.03.01, and PC.02.03.04). Traditional audits usually involve the use of a hand written format, requiring multiple entries of the same data to reach a statistically analyzable end-point. The implementation of the Electronic Medical Record in addition to (or in lieu of) a written record can further complicate objective collection of data by requiring the auditor to search between charts. The Respiratory Care Department at Memorial Hermann – Texas Medical Center sought to develop and implement a chart audit process that allowed for data entry directly to a database. No formal process was in place for audits. Capability would allow the department to utilize the Chart Audit as part of the Department’s PI efforts, and would allow trending data over time. Method: A Department-initiated PI project. A database was built that randomizes all charts associated with care provided by the department, and then queries an auditor to enter responses to presence/absence of documentation that supports the delivered care. These responses include Appropriateness of MD Orders, Interdisciplinary Plans of Care, Patient Education, Assessment of Response to Therapy, VAP Bundle requirements, and documentation of high risk/Sentinel Event indicators. Audits and Data Entry is performed by a trained group of Department Leadership. Data is automatically tabulated and scored, and is identified by Area and Shift. Results: The first month of data collected was considered as the benchmark of current performance (n= 137 charts). The overall baseline score was 70.3% compliance within the 10 evaluated areas. A threshold of 85% was assigned to all evaluated areas, with 5 of 10 (50%) of the scored areas below this threshold. Department scores were posted for staff review and discussion. Audit for the following 90 days resulted in an overall score of 73.8% (a 5% improvement), with threshold met or exceeded in 7/10 (70%) of the scored areas. Data collection is ongoing at this time. Conclusions: Design and implementation of this chart audit process has helped Department Leadership identify areas for improvement. Objective collection of data reduces/removes bias, and data entry error has been eliminated. This process has been incorporated into the Department’s Quality Improvement plan. Sponsored Research - None