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Use simple forms to improve post-operative note process

HIM Connection, December 5, 2006

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When a surgeon closes up, the job is not done. Before the doctor leaves the operating room, he or she must document what just occurred.

Because most surgeons dictate their postoperative reports, there's usually a lag of at least 12-48 hours before someone transcribes the reports and puts them in the record. Because the information on the procedure will be missing from the record during recovery and the hours after, physicians need to complete progress notes right away to give the basic information on the operation and the patient's condition.

Create a form or rubber stamp
In every hospital, about 10-25% of physicians don't complete progress notes after surgery, either because they were never told to or because they don't see the point, according to John Rosing, MHA, FACHE, senior consultant at the Greely Compnay, a division of HCPro, Inc.

Educating the medical staff about the requirement is the first step toward compliance. The next step is making it easy for physicians to quickly jot down the six items the JCAHO requires:

• Name of surgeon and assistant
• Technical procedure performed
• Findings
• Postoperative diagnosis
• Blood loss, if any
• Specimen removed, if any

"Forms design is important," says Rosing. "I have seen hospitals have success in taking the progress note form and modifying it for the postop case by including prompts with blank lines or check boxes for the six required items."

Hospitals can either create a form that includes the six items, or a stamp that goes directly in the progress notes section of the chart, he explains.

Tailor forms for specialties
For certain specialties, you can add the items required by the JCAHo to a form the physicans already use, says Rosing. For example, in the cardiac catheter lab, cardiologists often use a form with a diagram of the human body on which they can draw where they inserted and strung the catheter.

"You could take this rubber stamp, and somewhere over in the corner, stamp right on that form. That's going to facilitate the cardiologist then completing those six elements," he explains. "By adding the prompts to this form you can increase compliance."

At the Valley Hospital in Ridgewood, NJ, certain specialists use a version of a standard post-operative form tailored to their services, says Barbara Siegel, MS, RHIT, director of medical records.

"We use a similar form for cardiac catheter lab that has items specific to that service," she explains. "We also include some diagnoses on the catheter lab form for the MDs to check off."

Editor's note: The above article was adapted from the book Mastering Records Completion 2. For more information or to order, call 877/727-1728 or go to www.hcmarketplace.com/prod-1922.html.

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