Gail Wells, RN, director of outpatient clinical services at Berks Center for Digestive Health in Wyomissing, Pa., discusses how the center works to ensure clinical records are up-to-date and accurate.
Q: What processes are set in place to ensure clinical records are accurate and complete according to AAAHC standards?
Ms. Gail Wells: Basically, our assigned nurses go through patient charts at the end of the day every single day to make sure the history and physical examination on each chart is accurate and complete. Then patient charts go through a quarterly peer review process, so a physician will review another physician's charts and make comments on them, like 'no diagnosis was noted' or 'no pictures were taken during a colonoscopy.'
A lot of times, medical charts are checked while doing follow-up phone calls with patients to see how they're feeling. We try to breed that culture at the center to make sure the staff is checking charts all the time so that when it comes time to see a patient and a physician needs to pull a chart, everything that's required is already included and updated.
Q: How have you used information technology to help meet that goal?
GW: Berks Center uses an electronic system called GMed to fill in various operation note templates, including the pre-, inter- and post-operation note. So our nurses electronically enter pre-procedure notes to document what a patient ate or drank before the procedure takes place. Inter-operation notes allow nurses to electronically document what's going on during the actual procedure while in the OR, and post-operation notes are filled out to document level of consciousness and vital signs.
Physicians are also able to fill out their own operation notes electronically to document what the procedure was, if they did a biopsy, if there were polyps or tumors and how big they were, for example.
Learn more about Berks Center for Digestive Health.
Q: What processes are set in place to ensure clinical records are accurate and complete according to AAAHC standards?
Ms. Gail Wells: Basically, our assigned nurses go through patient charts at the end of the day every single day to make sure the history and physical examination on each chart is accurate and complete. Then patient charts go through a quarterly peer review process, so a physician will review another physician's charts and make comments on them, like 'no diagnosis was noted' or 'no pictures were taken during a colonoscopy.'
A lot of times, medical charts are checked while doing follow-up phone calls with patients to see how they're feeling. We try to breed that culture at the center to make sure the staff is checking charts all the time so that when it comes time to see a patient and a physician needs to pull a chart, everything that's required is already included and updated.
Q: How have you used information technology to help meet that goal?
GW: Berks Center uses an electronic system called GMed to fill in various operation note templates, including the pre-, inter- and post-operation note. So our nurses electronically enter pre-procedure notes to document what a patient ate or drank before the procedure takes place. Inter-operation notes allow nurses to electronically document what's going on during the actual procedure while in the OR, and post-operation notes are filled out to document level of consciousness and vital signs.
Physicians are also able to fill out their own operation notes electronically to document what the procedure was, if they did a biopsy, if there were polyps or tumors and how big they were, for example.
Learn more about Berks Center for Digestive Health.