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Clinical Documentation & Care Transition - 1

The document discusses clinical documentation and care transitions. It notes failures in documentation and communication contributed to misdiagnosis during the Dallas Ebola crisis. The document outlines when documentation is created during various stages of a patient encounter and care transition. It also discusses where documentation can be created and the different types of clinical documentation.

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Ethan Dyer
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15 views

Clinical Documentation & Care Transition - 1

The document discusses clinical documentation and care transitions. It notes failures in documentation and communication contributed to misdiagnosis during the Dallas Ebola crisis. The document outlines when documentation is created during various stages of a patient encounter and care transition. It also discusses where documentation can be created and the different types of clinical documentation.

Uploaded by

Ethan Dyer
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Clinical Documentation & Care Transition - 1

Krishnaj Gourab, MD. FAMIA


VP of Medical Affairs, Chief Medical Officer
University of Maryland Rehabilitation & Orthopaedic Institute
Associate Prof. Dept of Neurology. University of Maryland School of Medicine.
Adjunct Faculty, Johns Hopkins University, School of Medicine.
What went wrong?
What went wrong?

"The lack of complete history taking

documentation and sharing

ineffective communications among the clinical team

seeming overreliance on the EHR”

https://www.washingtonpost.com/news/to-your-health/wp/2015/09/04/failures-of-dallas-hospital-during-ebola-crisis-detailed-in-new-
report/. Published 9/4/2016. Accessed 9/6/2020
What went wrong?

Red flag at registration and nursing while collecting information

Visibility of the nurse’s note to the physician (later retracted)

Templated responses to questions

Critical thinking and situational awareness


Upadhyay, D. K., Sittig, D. F., & Singh, H. (2014). Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.
Diagnosis, 1(4), 283–287.
What is the solution?

“If I had an hour to solve a problem I'd spend 55


minutes thinking about the problem and 5 minutes
thinking about solutions.”

-Albert Einstein
When is documentation created?

Intake event Transition of care


(clinical encounter) event (discharge)

Encounter/ Episode of care


When is documentation created?

Intake event Transition of care


(registration) event (check out)

Encounter/ Episode of care


When is documentation created?

Intake event Transition of care


(registration) event (check out)

Encounter/ Episode of care


When is documentation created?

Intake event Transition of care


(registration) event (check out)

Encounter/ Episode of care


Post discharge navigator note

© 2019 Epic Systems Corporation. Confidential.


Patient generated documentation/data

© 2019 Epic Systems Corporation. Confidential.

https://www.hopkinsmedicine.org/epiwatch/index.html#.X1jPbnlKg2w. Accessed 9/6/2020


Patient generated documentation/data
When is documentation created?

Intake event Transition of care


(registration) event (check out)

Encounter/ Episode of care


When is documentation created?

Intake event Transition of care


(registration) event (check out)

Encounter/ Episode of care


Where is documentation created?

Emergency room Home care


Observation unit

Paper
Inpatient hospital Outpatient

Electronic
Inpatient in a post- Telemedicine,
acute-care facility Remote patient Completely made
monitoring up scale for
likelihood of
electronic
documentation
When kind of documentation is
created?

© 2019 Epic Systems Corporation. Confidential.


Clinical documentation: Role of the
informatician

Right information
Right person
Right format
Right channel
Right time

Sirajuddin, A. M., Osheroff, J. A., et. al. (2009). Effective CDS is essential for addressing healthcare performance improvement
imperatives. Journal of Healthcare Information Management: JHIM, 23(4), 38–45.
Institute of Medicine. (2001). Crossing the quality Chasm. A new Health System for the 21st. Century.

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