Health Information Management

A multifaceted approach to eliminating H&P deficiencies

JustCoding News: Outpatient, June 30, 2010

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Many hospitals seem to struggle with inconsistencies in the quality of their physicians’ history and physical exam (H&P) documentation, particularly when it comes to allergies and current medications. And the medical staff at Central Peninsula Hospital in Soldotna, AK, believed they were no exception, according to Marianne Dailey, RHIT, CHP, CPHQ, HIM director and privacy officer at the hospital.

So several months ago, Central Peninsula began to include the required elements for an H&P in the deficiency analysis process. It started by notifying the medical staff of the required H&P elements. After that, the HIM department documentation analyst reviewed the H&Ps for the required elements. If one or more elements were missing, it was considered deficient and sent to the physician for completion. The hospital began with a “no suspension” six-month trial period to build awareness and conduct education, which ended in March.

“At the end of six months, the new requirement was included in the standard process, which causes the physicians to be eligible for temporary suspension of privileges for incomplete records,” says Dailey. And it seems to be working. Physicians know that documentation is important, and as a result, Dailey is seeing fewer deficiencies.

Remind, alert, and repeat

In addition to the new process, the hospital is taking several other steps to mitigate the problem of H&P deficiencies. Triggering the physician to remember the various requirements early on is helpful.

Find different steps in the process to alert physicians of the H&P documentation requirements and what is missing, Dailey says. For example, she uses a little pocket guide for documentation requirements at her hospital. The guide is very colorful and approximately the size of an ID card, she says. It is given to medical staff members and is attached to phones from where they usually dictate. She uses it to remind physicians about everything from unapproved abbreviations to discharge summary and op note requirements to coding hot spots.

Involve your transcriptionists

To help the physicians, Central Peninsula transcription staff members leave H&P template sections blank when physicians do not dictate the information, instead of deleting the section names. For example, if the physician doesn’t dictate allergy information, the transcriptionist includes the heading but leaves it blank. “This way, when physicians go in to e-sign and they’re reviewing the document, they can see it is blank and fill it in at that point,” Dailey explains.

In addition, she has found that sometimes physicians embed allergies and medications into other paragraphs of the document. So Central Peninsula transcriptionists pull out the information. “This takes a little bit of time for transcription, but overall it is helpful for a follow-up physician just to be able to scan it and say, ‘Oh, here are the allergies,’ ” Dailey says.

Bolster buy-in

Dailey recognizes that much of the positive change she’s seen has been due to medical staff buy-in. “As an HIM director, you can do all kinds of audits and reporting but ultimately just end up frustrated if there’s no buy-in,” she says. “So you need for them to pick up the ball and take the lead.”

If you are struggling to get everyone on board with a similar program, remind physicians about how documentation issues affect them individually. “Usually what gets buy-in on projects is a personal ownership or some sort of personal impact,” Dailey says.

The medical staff may simply need a refresher on why a complete H&P will help them improve the treatment of each other’s patients, for example. And remind them how frustrating it is when they don’t get good information from other providers on patients they treat.

Editor’s note: This article was originally published in the June issue of Medical Records Briefing. E-mail your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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