Chart Completion

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Chart Completion

20-Mar-2018

Regina physicians have struggled to complete all discharge summaries and OR reports in a timely manner. Advice can only impact patient care if it is communicated in a timely manner. Regina's Area Chief of Staff will work with physicians to resolve this issue.

As you are aware Regina physicians have over the years struggled to complete all discharge summaries and OR reports in a timely manner. Timely completion of health records is important to patient care through its impact on the quality of care transitions between community and hospital based services. Patients and community colleagues value the advice they receive from hospital based specialists and services; as the provider of that advice I hope you too place great value on it. Advice can only impact patient care if it is communicated in a timely manner.

This has been an ongoing issue as demonstrated in the figure. Firstly, I would like to acknowledge vast majority of our physicians who complete their dictation on the day of discharge; this is much appreciated by your colleagues who as a result have that information available should a patient represent.

It is my intention to work with those physicians who have overdue charts to resolve this issue. Although I cannot undo prior initiation of disciplinary action, for those of you who have not been reported to Practitioner Staff Affairs there will be a three month period of heightened support starting on March 21st, following the Quarterly Practitioner Staff Meeting. Even the physician with the most outstanding charts can complete all of their charts in this time in less than an additional one hour per day. During the support period each Area Department administrative support will send any individual physician who has any charts awaiting dictation an email informing them of the number of charts in their dictation slot. Any physician who continues to have delayed completion of health records on June 20, 2018 will be immediately referred to their Area Lead for formal disciplinary process. Delayed completion of health records includes, but is not limited to, a delay of greater than 24 hours in completion of an operative report, and a delay of greater than 7 days for a discharge summary.

I ask that you complete your current charts first and then work on completing the overdue charts. In this way no new charts will become overdue and your current patients will receive improved transition care immediately.

Lastly, if a chart has been inadvertently added to your section, please let HIMS know as you become aware of the misdirection so they can rectify the situation. This will help us identify any HIMS related impacts on incomplete chart reporting.

I look forward to working with each of you who has struggled with overdue charts in the past. I would appreciate anyone who has a concern about their ability to complete their overdue charts within the three month period to contact me directly so that we can discuss a solution.

Submitted by: Dr. Juliet Soper, Area Chief of Staff - Regina