Pulmonology Procedures |

Documentation of Bronchoscopic Procedures: Templates Are an Effective Way to Improve Documentation and Audit of Bronchoscopic Procedures FREE TO VIEW

Julio Novelo*, MD; Amit Mann, MD
Chest. 2012;142(4_MeetingAbstracts):909A. doi:10.1378/chest.1382604
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SESSION TYPE: Bronchoscopy and Interventional Procedures Posters

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Bronchoscopy is a common diagnostic and therapeutic procedure performed by pulmonologists. The proper documentation of this procedure has wide implications, influencing clinical management decisions, communication of procedural findings and professional reimbursement. In an effort to improve the documentation, we report the development of a strategy which aims to improve the current documentation process.

METHODS: A Plan, Do, Study and Act mechanism was used to develop the Quality Improvement project. We did a retrospective one-month review of all bronchoscopic procedure documentation at a single tertiary care teaching hospital. Each document was evaluated for the inclusion or omission of specific components in a standard procedure note. Procedure documentation templates were developed to standardize the documentation process. Utilization of these templates was implemented after education of the fellows and faculty. After implementation, a second one-month review of all bronchoscopic procedure documentation was performed to identify the same standard procedure note components. Statistical analysis determined the frequency of appropriate documentation and assessment of change after intervention using statistical analysis from categorical data and Fisher's exact test to analyze the statistical significance of the p value.

RESULTS: Pre-template review included 62 procedure notes, 88.7% dictated and documented by fellows and cosigned by faculty and 11.3% were documented by faculty. Post-template review included 74 procedure notes 63.5% dictated and documented by fellows and cosigned by faculty and 36.5% were documented by faculty. Comparison of pre and post-template review revealed improvement (P<0.05) in documentation on pre and post diagnosis procedure, summary and full description of procedure, blood loss, complications, samples obtained for analysis, findings discussed with patient and continuity of care in our clinic.

CONCLUSIONS: Templates are an efficient, accurate, and timely strategy to avoid omissions of important information when documenting bronchoscopic procedures.

CLINICAL IMPLICATIONS: Appropriate documentation is an important aspect of patient care with multiple implications; it may improve patient care, practice behaviors, coordination of care between medical staff and professional reimbursement. A simple procedure template can be used to optimize documentation as well as subsequent continuity of care.

DISCLOSURE: The following authors have nothing to disclose: Julio Novelo, Amit Mann

No Product/Research Disclosure Information

, Temple, TX




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