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Monitoring Missing and Unsigned Notes in Ambulatory Psychiatry
The Problem
The Results/Progress to Date
Timely and complete documentation facilitates patient care and strengthens
decision- making. In June 2013, BIDMC updated its ambulatory
documentation policy requiring all notes be completed and signed within 7
calendar days after the outpatient visit. Although the Psychiatry Department
currently runs regular reports to identify unsigned and missing notes, these
reports are run separately making it difficult to track whether notes are
completed and signed in a timely fashion.
Aim/Goal
Our goals for this project were to
Create a system to integrate both missing and unsigned ambulatory visit
notes
Automate that report
Decrease the number of ambulatory notes designated missing or
unsigned more than 7 calendar days after the date of service.
The Team
Denise Doucette, Finance Manager
Rohn Friedman, MD, Vice Chair
Stephenie Loux, MS, Quality Improvement Data Analyst
Pamela Peck, PsyD, Clinical Director
Lessons Learned
While the majority of providers have few notes >7 days, a small number
of providers have high numbers of incomplete notes. The Clinical
Director is working to identify the causes to help staff eliminate the
backlog of missing and unsigned notes.
Notes awaiting co-signature do not show up in the current reports
The Interventions
Run weekly CCC OMRVN report for Psychiatry’s HMFP and Training
Clinics
Create automated summary and individual provider reports with
missing/unsigned notes categorized as <7, 7 to 13, and 14 or more days
after visit
Distribute individual reports to clinicians and summary report to Clinical
Director
Provide clinicians with assistance in resolving errors in missing notes
report
Monthly data summary for Departmental Management Report
Contact those with missing/unsigned notes > 14 days past due and
schedule an appointment with Chief of Psychiatry as per BIDMC policy
Next Steps/What Should Happen Next
Develop individual plans with providers who have high numbers of
missing and unsigned notes > 7 calendar days past the date of service.
Examine the feasibility of adding notes awaiting attending cosignature
For more information, contact:
Pamela Peck, PsyD, Clinical Director
ppeck@bidmc.harvard.edu
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Pamela Peck ( <a href="mailto:ppeck@bidmc.harvard.edu">ppeck@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Psychiatry
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Denise Doucette<br />Rohn Friedman<br />Stephenie Loux<br />Pamela Peck
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Monitoring Missing and Unsigned Notes in Ambulatory Psychiatry
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Safety
Timeliness