ANALYZING PHYSICIAN

TRENDS WITH PAPER

RECORDS IN AN
ELECTRONIC WORLD
PRACTICUM PROJECT
BY
DANGELO CAPELL

PROJECT GOAL STATEMENT

THE PROJECT GOAL IS TO ANALYZE PHYSICIAN TRENDS IN THEIR USE OF

PAPER PATIENT HEALTH RECORDS AT SELECT SPECIALTY HOSPITAL
CINCINNATI TO MAKE SURE THAT THEY ARE COMPLIANT TO JOINT
COMMISSION STANDARDS.

PROJECT SCOPE
THE PURPOSE OF ANALYZING PHYSICIAN TRENDS WITH PAPER RECORDS AT SELECT SPECIALTY
HOSPITAL CINCINNATI WAS TO MAKE SURE THAT THEY ARE COMPLIANT WITH JOINT COMMISSION
STANDARDS. TO MAKE SURE THAT RECORDS WERE COMPLIANT, THE FOLLOWING STEPS WERE
TAKEN:
1) REVIEW MULTIPLE CHARTS OF CURRENT PATIENT RECORDS FROM THE (4) MAIN ATTENDING
PHYSICIANS AT SELECT SPECIALTY HOSPITAL CINCINNATI.
2) REVIEW CHARTS LOOKING FOR PATIENT MIX UPS BECAUSE SELECT SPECIALTY HOSPITALCINCINNATI HAS NOT CONVERTED OVER TO ELECTRONIC RECORDS YET.
3) DOCUMENT WHAT IS MISSING FROM THE RECORD THAT MAKES IT INCOMPLETE AND
NONCOMPLIANT.
4) COMMUNICATE WHAT IS NEEDED FROM THE ATTENDING PHYSICIAN(S) TO MAKE THE
MEDICAL CHART COMPLETE AND COMPLIANT.

DELIVERABLES
THE DELIVERABLES OF THE PROJECT
WITH AN UPCOMING VISIT FROM THE JOINT
COMMISSION DURING THE WEEK OF 4/18/16, THE TWO
WEEKS SPENT AUDITING MEDICAL CHARTS AT SELECT
SPECIALTY HOSPITAL CINCINNATI WILL HELP THEM
ACHIEVE COMPLIANCE WITH THEIR RECORDS AND
MAINTAIN THEIR ACCREDITATION.

List of
Resources
Resources used for this project are as follows:
Site Director, Julie Brannock
Medical Charts
PC
Summary of Findings Sheet(s)
Color Tabs
Scanner
Copying Machine

RISKS
THE CHALLENGES OF THE PROJECT WERE

NOT BEING ABLE TO FULLY REVIEW A CHART DUE TO NURSE OR PHYSICIAN DEMAND
CHALLENGE OF THE POSSIBILITY OF PATIENT INFORMATION BEING MIXED UP DUE TO
SELECT SPECIALTY HOSPITAL USING PAPER RECORDS.
WITH SO MANY PAPER RECORDS, SPACE CAN BE A FACTOR AT TIMES
NOT BEING ABLE TO READ A PHYSICIANS HANDWRITING
PHYSICIAN COMPLIANCE ON PROVIDING DATE, TIME, OR SIGNATURE IN A TIMELY MANNER

TASK OUTLINE
Task Name

Duration

Start

Audit 2 patient
charts

1 hour

Discussion about
Project

1hour

4/7/16

4/7/16

Gather medical
charts of the main
attending Physicians
at Select

4 hours

4/7/16

4/12/16

1 hour

4/12/16

4/12/16

Project Plan
Formulated
Prepare for
upcoming Joint
Commission visit
Audit 4 patient
charts

4 hours

2 hours

15 minutes

4/7/16

Finish
4/7/16

4/12/16

4/12/16

4/12/16

4/12/16

4/12/16

4/12/16

Project Timeline
March 28th April 1st -I received my Site Supervisors contact
Information
April 4th April 8th -Contacted Site Supervisor
April 4th April 8th First Meeting with Site Supervisor
April 4th April 8th -Introduction to Staff
April 4th April 8th Tour of Facility
April 4th April 8th Discussion of HIM role
April 4th April 8th Credentialing
April 4th April 8th Audit 2 patient charts
April 4th April 8th Discussion about Project
April 11th April 15th Project Plan Formulated
April 11th April 15th Audit 4 patient charts
April 11th April 15th Tally Information Received
April 11th April 15th Go over Project Outline
April 11th April 15th Plan Final Meeting/Discussion about Project

SUMMARY

THIS SEMESTER, I ELECTED TO DO MY PRACTICUM AT SELECT SPECIALTY HOSPITAL CINCINNATI. SELECT SPECIALTY HOSPITAL CINCINNATI IS A 35 BED HOSPITAL
THAT IS LOCATED INSIDE OF GOOD SAMARITAN HOSPITAL ON THEIR 15TH FLOOR. MY SITE DIRECTOR FOR THE PRACTICUM WAS JULIE BRANNOCK. AFTER THE
INITIAL MEET, JULIE INTRODUCED ME TO OTHER STAFF MEMBERS, GAVE ME A TOUR OF THE FACILITY, AND EXPLAINED TO ME THE ROLE OF HER POSITION AS HIM
DIRECTOR AT SELECT AS WE SETTLED INTO HER OFFICE. SELECT SPECIALTY HOSPITAL HAS NOT YET MADE THE TRANSITION OVER TO EHRS WHICH MEANS THAT ALL
OF THEIR FILES ARE CURRENTLY PAPER RECORDS. I NOTICED HOW HER OFFICE WAS FILLED WITH PAPER CHARTS, RECORDS, AND FILES. SHELVES FILLED WITH
CURRENT CHARTS, DISCHARGED CHARTS, RECORDS IN RETENTION, AND A WHOLE CABINET FULL OF PHYSICIAN CREDENTIAL APPLICATIONS. THE LACK OF EHR
IMPLEMENTATION CAN BECOME A BIG ISSUE AT TIMES FOR RECORD COMPLIANCE. WHILE I SPENT MY TIME THERE, I NOTICED HOW A CURRENT CHART COULD NOT
BE FULLY AUDITED DUE TO A NURSE(S) COMING IN AND DEMANDING/REQUESTING TO SEE IT, HOW SOMETIMES REQUESTING A PHYSICIAN SIGNATURE CAN BECOME
A BIG TIME HASSLE, AND HOW LEGIBILITY COULD ALSO RAISE ISSUES.

FOR MY PROJECT, WE DECIDED THAT IT SHOULD BE ABOUT AUDITING/ANALYZING CHARTS AND HOW MAKING SURE THAT IT IS JOINT COMMISSION COMPLIANT CAN
SOMETIMES BE DIFFICULT DUE TO SELECT STILL USING PAPER RECORDS. FOR THE RESEARCH OF MY PROJECT, I USED 4 CURRENT CHARTS FROM THE 4 MAIN
ATTENDING PHYSICIANS AT SELECT SPECIALTY HOSPITAL CINCINNATI. MY SITE DIRECTOR INFORMED ME TO LOOK FOR SIGNATURES, DATES, AND TIMES THROUGH
EACH RECORD. JULIE ALSO INFORMED ME BEFORE I STARTED THAT LEGIBILITY AND SIGNATURES HAVE IMPROVED OVER TIME DUE TO HER HOUNDING, FAXING,
DISCUSSING, OR EVEN SUSPENDING CERTAIN PHYSICIANS DUE TO THEIR NONCOMPLIANCE BUT THAT IT IS STILL AN ISSUE AT TIMES. WHILE AUDITING, I NOTICED
THAT OF THE 4 PHYSICIANS CHARTS, LEGIBILITY WAS DEFINITELY A MAJOR ISSUE FOR 1 OF 163 PHYSICIAN ORDERS AND PROGRESS NOTES, LEGIBILITY WAS A
CONCERN FOR 44 OF THOSE AND THEY ALL CAME FROM THE SAME PHYSICIAN.

IN MY TIME AT SELECT SPECIALTY HOSPITAL CINCINNATI, I NOTICED THAT THE PHYSICIAN TRENDS WERE MOSTLY COMPLIANT. I AUDITED QUITE A FEW CHARTS
EVEN LOOKING TO SEE IF ANY PATIENT INFORMATION MAY HAVE LANDED IN THE WRONG PATIENT CHART BUT I NEVER CAME ACROSS THAT. ALL 4 PHYSICIANS TIMED
AND DATED SOMEWHERE NEAR THEIR SIGNATURES AND 75% OF THE PHYSICIANS CHARTS WERE LEGIBLE. I WOULD GUESS THAT THE FEW CHALLENGES THAT I
FACED FOR THIS PROJECT ARE COMMON ISSUES AMONG FACILITIES THAT HAVE NOT YET TRANSITIONED OVER TO ELECTRONIC RECORDS. WITH ELECTRONIC
RECORDS IN PLACE LEGIBILITY, TIME & DATE, AND SIGNATURE REQUESTS AND CONSTANT REMINDING WOULD DEFINITELY DECREASE.

SURVEY TOOLS
Records that were Signed, Dated, and Timed
4th Qtr
Physician 3
Physician 2
Physician 1
0%

20%

40%

60%

80%

Records that were Signed, Dated, and Timed

100%

120%

SURVEY TOOLS
Physician Charts that were Legible
120%
100%
80%
60%
40%
20%
0%
Physician 1

Physician 2

Physician 3

Physician Charts that were Legible

Physician 4