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  Auditing Patient Progress Notes Practicum

Project Description

Background of the Project

Among the major causes of death globally are medical errors committed by care providers. Specifically, medical errors ranks the eighth among the leading causes of death in the United States (U.S.) (Kettenbach & Schlomer, 2016). van Gelderen et al. (2018) explain that medical errors cause significant morbidity and account for about $14.7 billion yearly in direct health care costs within the U.S. Studies on this topic in other regions or countries have shown similar results (Archer, 2017; Waterson, 2014). Patient safety, which is defined as liberty from accidental injury, has for that reason become a principal issue of health care providers, policymakers, and the general public. It is against this knowledge that I will reflect on my practicum that I recently took.

My Practicum Project was at the Veterans Affairs Hospital (VAH) in Newington, CT. My main mandate during the practicum was to audit patient progress notes in the Health Information Management (HIM) department. I had to ensure that all the patient progress notes have the required data as directed by the Joint Commission. That is, I had to highlight the discrepancies between actual contents of the patient notes and the standard procedures based on evidence based practice to enable identification of the changes required for improvement of quality of care.

I also realized that the Joint Commission had a special role of safeguarding the safety and quality of care given to the public. For instance, they are involved with the provision healthcare certification and related services for promoting performance improvement in healthcare organizations. To obtain its objectives, the Joint Commission focuses on specific areas of care such as practices related to timely care, infection prevention and controls as well as organizational leadership and culture of healthcare organization. The mandate of the commission is in line with the policies of VAH since both are tailored towards ensuring positive patient outcome and ensuring patients receive the highest standard of care.

In auditing the patient progress records, I noted that I was vulnerable to making mistakes since the process was so tedious and time-consuming. For this reason, I would like to conduct research in future using available literature on some of the best practices to be followed in ensuring accuracy and efficiency in the whole process.

Problem Statement

Clinical auditing concerns measuring the quality of healthcare that is provided by care providers to patients against some relevant standards. In case a care facility fails to meet the standards that inform their dealings, the audit ought to assist the care facility to understand the factors that are contributing to their failure to realize the organization’s objectives so that they can set priorities as well as make advancements (van Gelderen et al., 2018). This is because a number of patients encounter adverse events during their stay in care facilities. The occurrence of the undesirable events varies between 3% and 18% of all care facility admissions globally (Kettenbach & Schlomer, 2016; Hutchinson, 2017; O’Riordan, 2018). To gain insight into care facility quality of care, valid and reliable data regarding an occurrence, its causes, as well as preventability of undesirable events have to be gathered and made accessible or available. Among the techniques that are commonly employed for analyses of unsafe care facility care as well as improvement of patient care safety include external peer reviews, accreditation, patient safety systems, internal audits, along with performance indicators (Gomes et al., 2016; Wise & Draper, 2017).

Further, to sufficiently gather insight into a hospital care, an internal audit ought to be carried out. According to Archer (2017), the internal audit ought to be an objective, independent assurance and consulting system aimed at timely detection and identification of patients’ dangers of undesirable events. The audit ought to encourage the continuous advancement of patient care and quality. An internal audit functions to help an organization to realize its objectives and goals by offering a methodological, disciplined approach for assessing as well as bettering the effectiveness of risk control, management, and governance processes (O’Riordan, 2018; Chaiyachati et al., 2014). One of the greatest advantages of auditing is that it may reveal the causal causes of safety challenges and may give care providers clues to which advancement ought to be made to avert undesirable events (Waterson, 2014; Gomes et al., 2016).

As indicated earlier, my practicum assignment gave me an opportunity to work with the Veterans Affairs Hospital in Newington, CT where my work entailed auditing patient progress notes in the Health Information Management (HIM) department.  A patient progress note often refers to a medical document written by a physician indicating the status of the patient according to the physician’s assessment as well as the treatment plan for the patient. In auditing the patient progress notes, I had to ensure that the patient notes contained the essential information as required by the Joint Commission.

Since a comprehensive and accurate record keeping is an integral aspect for realizing adequate patient care and continuity of care between different healthcare providers, auditing of patient progress notes is vital.  This is because it ensures that such records are of high quality and that their contents reliable. However, for results of the auditing process to be accurate, Bowie and Green (2016) give basic steps that must be followed. First, one must focus on specific area to be audited such as inconsistence in any piece of information. Also, the auditor must specify the type of records to review for auditing. This may be based on gender, treatment regimen or age of the patients.

Making decision on the size of patient data to be included in the auditing process is equally necessary for promoting accuracy in the process. An auditor must develop an effective record keeping tool that will best record the findings of the audit. As Bowie and Green (2016) observes, electronic data storage is mostly recommended due to its ability to organize the recorded information and promote future usability of such information. Giving summary of the findings is also necessary.

According to the scholars, summary allows for the removal of irrelevant data and facilitates organizing data in a way that makes it most impactful. Another important practice in the audit process entails analyzing the data with the aim of implementing suitable practice. It entails identifying specific inconsistency patterns and omission of certain procedures and informing the relevant authorities to add such omissions to the standard protocol. It is on this background that in this paper, the best practices involved in auditing patient progress notes as well as its application areas are discussed.

Project Objectives

The objectives of this project were as follows:

1. To determine why patients visiting to the care facility was listed.
2. To determine whether physicians reported present illness.

• To establish whether physicians document any diagnosis.

1. To determine the percentage of accuracy rate.
2. To determine the areas that needed improvement.

As such, to meet the above objectives, the following topics will be audited:

1. Is the reason for the visit listed?
2.  Is the physician reported present illness?
3.  Did the physician document any diagnosis?
4.  Total numbers of yes and no
5.  Percentage of accuracy rate
6.  Percentage of area need improvement
7.  Chart to compare and contrast

Project Research Plan and Design

The research design for this study involved a review and audit of the progress note of the facility’s outpatient. 20 patients were randomly selected for the study. The sample population came from visits to VA’s primary care. The selected period for the study was from October 1, 2018 to October 30, 2018.

Since the auditing process is a continuous one, I began with selection of standards. This involved setting VA’s standards or adopting existing guidelines or standards. After this, I proceeded to carry out the audit (or assessing the outcomes of ongoing evaluation) as well as identifying where VA was failing to meet its desired standards. Next, I took turn to identify the factors that are making VA to fail to realize its standards, setting priorities, as well as taking actions aimed at bettering what the VA did, checking whether VA had improved (by carrying out a complete re-audit or through monitoring of either one or more indicators) and finding other possible solutions if it had not improved. Finally, I repeated the cycle for reasons of identifying and addressing the next set of challenges. It is important to note that every single time an audit cycle is accomplished, there ought to be further advancement in the quality of patient care.

Research and Literature Review

Undoubtedly, timely detection of clinical errors and discrepancies in the quality of care provided to patients is crucial in medical practice. According to Wise and Draper (2017), timely identification of clinical errors and discrepancies, including responses to front line medical staff, is among the prerequisites for forced patient safety improvement. However, detection techniques ought not only to capture preventable undesirable occurrences, but they as well need to consider defects or failures in the reliability and validity of the system of healthcare that places patients at danger for injury in the future (Waterson, 2014). Several detection techniques are presently being employed by health care institutions. These include chart auditing, voluntary incident reporting, and automated data mining of pharmacy, laboratory, and case mix data. However, owing to some limitations that characterize these tools, other techniques like statistical control processes, checklists, lean production, continuous quality advancement, blame free reporting of patients’ near misses, failure mode, root cause assessment errors, and effects assessment (Archer, 2017).

From the project description, it is evident that the Joint Commission significantly role plays in ensuring safety and high quality care is given to patients at any single time. During the practicum, I had to highlight any discrepancies between patients’ notes’ actual contents and the standard procedures based upon proof-based practice to enable identification of the changes that are needed for improvement of the patients’ quality of care (Gomes et al., 2016). Additionally, the Joint Commission was involved in the provision of healthcare certification alongside associated services for promoting performance improvement within health care organizations (Chaiyachati et al., 2014). To realize these objectives, Waterson (2014) observes that the Joint Commission concentrates upon specific areas of healthcare like practices that are related to timely care, infection controls and prevention and organizational leadership along with culture of health care organization.

The Joint Commission is an independent, non-profit making organization that was founded in 1951 (Chaiyachati et al., 2014). The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value (Bowie & Green, 2016). The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations (The Joint Commission). The organization runs a number of efforts in service of its mission. These include: processes that are related to timely access to care for patients, processes that may potentially indicate delays in care and diagnosis, processes related to patient flow and coordination of care, infection prevention and control, the environment of care, and organizational leadership and culture (van Gelderen et al., 2018). See appendix for more information on the Joint Commission.

Outcomes of the Project

The results of this study are as summarized in the tables 1 and 2 and bar graphs 1 and 2 are as shown below.

Table 1 VA-Out Patient Health Record Audit

Table 2 Accuracy and Improvement Percentage of Each Criteria

Figure 1.  Accuracy and improvement percentage of each criteria

Summary and Conclusion

Regarding this project, a total of 20 randomly selected patients were review from the month of October 2018. Surprisingly, we found four same errors from Flu shot clinic with no present illness and reason for visiting was noted. In addition, the clinic only obtained verbal consent with no patient signature. In another case, I found that patient was checked out, but there were no notes attached to his encounter. In conclusion, my finding is that physicians and staff are more likely to enter the diagnosis code instead of typing patient reason for visiting and their present illness.