Member Resources

Member Login

Gateway Center
2140 W. County Road C
St. Paul, MN 55113

(651) 636-3890
Fax (651) 636-3894

Assuring Quality Assurance:
Computerized Documentation

By Patricia Jump, RN, MA

As Director of Client Services, I have the eminent privilege of completing quarterly chart audits for our five branch offices. While the task of concluding the audits is somewhat massive in itself, the responsibility I approach with even greater trepidation than the audit is reporting all of the missing or inaccurate charting elements to the nurses responsible for maintaining accuracy of the client records. Since we began computerized documentation, reporting audit findings is much less burdensome for myself and for the nurses completing the client records.

Charting by computer (CareFacts™) has resulted in far fewer missing and erroneous components within the client record. Now, instead of shuffling a 16 page data base when gathering information during an initial intake process, the nurse scans a computer screen, one item at a time. The nurse must purposefully decline to address the item on the computer screen in order for it to show up as a missing item on the chart audit.

When documenting a review of the client's body systems, CareFacts presents the nurse with a pick list of items. This results in a more exhaustive assessment in a brief period of time since the nurse in continuously prompted by a pick list which includes all of the body systems as well as words prompting a detailed evaluation within each body system. Therefore, details of the assessment are not forgotten and less time is spent in remembering or looking up needed information to complete a detailed assessment.

Creating a care plan is also simplified through the use of CareFacts. Body systems are assessed in the Assessment portion of CareFacts. Problems which are identified as actual (not potential) are automatically transferred to the care plan. CareFacts then allows nurses to visualize potential outcomes and interventions for each of the identified problems, It also allows free-lance writing to add client specific information unique to each client. This facilitates a quality assessment generating evidence of medical necessity, which mandated by most third party payors.

Ongoing evaluation of the nursing diagnoses in also assured when using CareFacts. Addressing each care plan problem becomes virtually methodical since problems automatically appear on the skilled visit report screen as the nurse documents the visit. The nursing problems must either be addressed or purposefully bypassed. Consequently, nursing problems listed on the care plan are addressed and evaluated in a timely manner.

Outcomes for each care problem also are visualized with each skilled visit report. Both the current status of the outcome goal and the actual desired end outcome are on the screen with each nursing visit report. Progress toward established goals are evaluated frequently and the need to change interventions to meet the goals, or reassurance that current interventions are working well, becomes readily apparent.

Additionally, absence of Medicare-mandated information such as recording homebound status and caregiver supervision is no longer an issue with the audit since there are word triggers that mandate a response from the nurse when documenting the skilled visit.

Prior to computerized documentation, matching physician orders, especially medication orders to current medication sheets, was an ongoing process which frequently resulted in errors simply based on human failure as physician orders were transcribed to medication sheets. With CareFacts, data is entered one time and then is automatically transferred (don't ask me to explain HOW it's transferred - it's one of those computer things!) to other forms in the documentation system.

For example, medications in the database section of the chart are automatically transferred to the medication sheet used as the ongoing record of medications. These same medications are simultaneously transferred to the 485. This automatic transmittal of information eliminates errors generated when data is documented in multiple sites within a client record. If medications are added to the client treatment plan, the nurse enters the new medication only one time. From that point of entry, an interim physician order is generated to forward immediately to the physician and the new medication is added to the 485 so that the change is already there at the time of recertification. This results in more accurate information in the client record.

At this time, for all five branches, it takes two nurses approximately six days to complete full chart audits, Since audits are completed quarterly, two nurses spend 24 days a year completing chart audits. This means 48 days of nursing time are spent annually completing chart audits. CareFacts is currently developing audit reports which will perform these chart audits automatically, using the existing chart data.

In summary, the errors and the number of missing items or missing information has decreased markedly with the use of computerized documentation. Chart audits are easier and needed corrections are fewer. Additionally, once the computer-generated audit reports are available from CareFacts, time spent on the actual process should be drastically reduced.

Citation: Jump, P. (1994). Assuring Quality Assurance: Computerized Documentation. The Quality Messenger, 1(3), 1, 2, 4.

[back to top]