Back to Documenting Patient Care: The Path to High-Quality Health Indicators
Transcript
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CIHI presents
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Charting the Path to Better Patient Care
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Dr. Chris Simpson
Cardiologist, Kingston Health Sciences Centre
Chris Simpson
Hi. I'm Dr. Chris Simpson. Every day we hear and read reports about the quality of care being delivered to Canadians. Sometimes, they tell us that things are in good shape, while other times we're told health care outcomes need improving.
Have you ever wondered what your role as a clinician is in how health information gets collected, analyzed and reported? Well, it all starts with the patient chart.
[Image of a medical doctor assessing a patient in their office, along with images of patient documentation in various formats.]
When you see a patient, you're gathering information about symptoms, medical history and preexisting conditions.
[Images of an X-ray, a test tube and a blood pressure cuff.]
You're also ordering tests and making diagnoses. All of this information is used to inform how care is delivered, to drive quality improvement, and to support better patient care and health outcomes.
And did you know that the patient chart information that you collect and document is the foundation that helps measure the performance of our health systems? Let's dig a little deeper into how this works.
When a patient is discharged from hospital, much of the information you documented in their chart gets coded using systems called the International Classification of Diseases, or ICD, and the Canadian Classification of Health Interventions, or CCI. ICD and CCI are common language tools used to classify and code diagnoses, symptoms and procedures.
The Canadian Institute for Health Information, or CIHI, maintains these systems in Canada.
[Image showing CIHI’s office receiving codes from a patient’s chart and outputting data in the form of indicators.]
CIHI uses these codes, along with other information from the patient's chart, to provide comparable and actionable data so that health care providers and organizations like yours can measure and improve the way we deliver health care in Canada.
[Image showing a doctor working at their desk.]
As clinicians, we all know that recording details in patients' charts takes time. So how comprehensive does this information need to be for it to be useful down the line? Let's look at an example.
[Image showing a senior sitting in a wheelchair followed by an image of their patient chart.]
Meet Larry. He was admitted to hospital for a hip replacement. His medical history indicates that he has type 1 diabetes. While in hospital, he develops pneumonia. So you add the following notes to the discharge summary in his chart.
[Image showing a discharge summary noting that the patient has pneumonia, antibiotic resistance and type 1 diabetes.]
After Larry is discharged, your hospital's health records team assigns ICD and CCI codes based on what you documented.
[Image showing coders working with the information retrieved from patient discharge summaries.]
The more detail you include in Larry's discharge summary, the richer this information will be.
Larry's record, along with hundreds of thousands of others, will be used in developing indicators that help monitor outcomes. Because you noted the bacteria were resistant to the antibiotic methicillin, Larry's record will be included in the calculation of indicators like in-hospital infections and other patient safety measures.
This also affects the calculation of things like the expected length of stay and total cost, which would have been different than if you hadn't included this piece of information.
And because you noted that Larry has type 1 diabetes, we now have important patient risk information that will be taken into account for indicator calculations and comparisons. In turn, these indicators can help you manage the care you deliver to patients.
So what's the prescription for a comprehensive patient chart?
Specificity about diagnoses, examination findings, comorbidities, discharge information and so on.
Don't leave anything out. Watch for missing, incomplete or conflicting information.
Now you can see how high-quality chart documentation results in high-quality data. This means we can all have confidence in the information we use to support quality improvement and, ultimately, in understanding how our health systems are performing, helping us as clinicians deliver the best care to our patients.
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Canadian Institute for Health Information
Better data. Better decisions. Healthier Canadians.
www.cihi.ca