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Chart Auditing, Reviewing, and Printing

Article Quick Links:

1. From the “Overview Page” – Audit “Allergies” and “Care Plan Updates”
2. Auditing “Medications Profile”
3. Auditing “Notes”
4. Auditing “Orders”
5. Auditing via PIM Reports
6. Printing Entire Chart for QAPI or Medicare ADRs
   1. Unarchiving Records
   2. Viewing and Printing

mumms Software provides many reports to assist managers in oversight of the hospice agency. Make sure to get familiar with the PIM REPORT Module as well as the Tip Sheets relating to reports. These are:

• Introduction to Reports
• Reports Inventory
• Reports BI Data Dictionary
• HIS HQRP Data Report

In addition to this tip sheet and the above-mentioned tip sheets, the following should be thoroughly read and understood:

• Medical Records
• Surveys and ADRs
• Print Chart App

Listed below are several ideas on chart reviews and monitoring topics. It is, by no means, an exhaustive list. Suggestions for needed reports are always welcomed at mumms Software.

A. From the “Overview Page” – Audit “Allergies” and “Care Plan Updates”

1. Check that allergies are accurate by viewing the allergies entered via HBC and comparing to the allergies entered via PIM.
   1. Do this by running the PIM Allergy report and comparing it with the allergies in HBC.
   2. Make sure the allergies match.
   3. Make sure each patient has allergies documented both in the chart and face sheet.
2. See the listing of Care Plan Problems.
   1. Any missing? (i.e. agency policy may require the “Resuscitation Care Plan” to be completed on all patients.
   2. How long since last updated? Compare “created on” date with “last updated” date.
3. Expand the “Notes” section to see if “Care Plan Notes” are being utilized to report the outcome towards goals.

B. Auditing “Medications Profile”

1. To audit this section, you may be looking for all the details of the medication to be complete, i.e. dose is a required question, but you may be auditing for route, frequency, purpose, if the medication is covered by hospice, start and end date.
2. While auditing medications, you may want to confirm you have an “Order” created for each medication change on the profile.

In HBC, use the right pane, click on the down arrow and scroll down to the Orders list, you should see a New Physician Order to match the date of the medication change (orders archive generally after 90 days, so it may not be there if it is older). In HBM, expand both the “Orders” section and the “Medication” section and compare.

C. Auditing “Notes”

1. This is an easy way to quickly scan the chart to see if the care plans are being addressed r/t outcomes and evaluation of interventions.
2. You are easily able to see if care plans are being noted on at least every 15 days.
3. You are able to determine if all disciplines are addressing the care plans.
4. You are also able to see if addendums have been made to Forms.
5. If you see Progress Notes (i.e. an expansive note relating to the patient’s condition) in this section, it is likely that the worker is using the right pane incorrectly. They are likely documenting notes from a phone call or visit and this is not the correct place to do it! Remind them to select the form called “Progress Note” in the Forms section of the chart (this allows for better organization of the chart when printing/viewing).

Note that goals and interventions should be updated as the patient’s condition changes in addition to using “Notes”. The care plan must be “edited” in order to modify/add/delete a goal and/or intervention.

D. Auditing “Orders”

1. The way the program was intended to be used, after each order is signed by the physician or the IDG/IDT is over, the Order should be Resolved. This ensures the auditor that the document has a signature and that someone saw that signature.
2. If you have the attachment feature and are using it, you can look in attachments to confirm the order is there and signed.
3. In the REPORTS module in PIM find “Created Orders”, “Resolved Orders” and “Unresolved Orders” reports to assist in monitoring that all orders are being signed in a timely fashion.

E. Auditing via PIM Reports

From PIM, choose the “Reports” module. The following are some ideas for using the reports to cultivate a robust CQI program within the hospice organization.

1. Length of stay monitoring (see reports under “Utilization”)
   1. Current Census: view the number of patients on service today for more than 180d
   2. Pt and Pt Days by LOC: sort by “discharge date”. View the number of patients on service for less than 7 days.
   3. Comprehensive Summary: enter the date range of multiple months. View ALOS, total pts >180d, <7d; compare month-to-month
2. Visit Monitoring (see reports under “Clinical”)
   1. Variance Report—pulls the documented frequency on the Visit Schedule Care Plan problem by discipline and compares with actual direct care visits by discipline. Both “summary” and “detailed” version are available.
   2. HIS Discharge Report—monitor # and type of visits made in the last 7 days of life (found under “Miscellaneous/Regulatory”)
   3. Visit Summary by Week allows monitoring of the number of direct visits by a staff member. Compare with “Assignments” detail/summary reports (found under Utilization)
   4. Supervisory Visit Reports sorted by Pt MR# and “Visit date” can easily be scanned to ensure that Sup Visits are being done every 14d for HHAs and per company policy for LPNs.
   5. Questionnaires by Visit—allows comparing visit type with forms, care plans, and orders that were completed on that visit
      1. Ensure all necessary documents are completed during Initial Visit
      2. Endure direct care visit type is not used to document a telephone call, etc.
3. Symptom Monitoring (see under “Clinical” reports)
   1. Use the reports “Moderate to Severe Pain/Anxiety/Depression/Nausea/Dyspnea” to identify patients with problems. Review the chart to ensure the patient’s symptom was addressed.
   2. For patients with Moderate or Severe pain or anxiety, use the “Pain over Time” and “Anxiety over Time” to track the patient’s response to therapy. i.e. Was pain better within 24h? Was there a f/u visit?
   3. Reports “Patients with Increasing Pain” and “Patients with Increasing Anxiety” graph any patient whose symptoms are increasing.
   4. Falls: review chart for preventability; care plan present?
   5. Infections: This report shows patients who did not have an infection at admission but developed one. Chart review to determine preventability; Foley? Risk factors?
   6. Patients with Impaction: review chart to determine if a bowel regime was in place; preventable?
   7. Patients with Stage III or IV Wounds: adequate treatment? Preventable? Care Plan?
4. Various statistical data points can trigger CQI monitoring, such as:
   1. Number of revokes by reason—See Comprehensive Summary Report
   2. % of GIP days- See Comprehensive Summary Report
   3. Volunteer Usage—See Visit Summary by Month-Volunteers
   4. Patients going to ER/Urgent Care—review charts to determine preventability

F. Printing Entire Chart for QAPI or Medicare ADRs

In the event you need to review and/or print the chart:

1. Unarchiving Records

If a chart has been archived, it will be listed as “Yes” or “Super” on the HBC Patients listing screen under the Archived column.

Super Archived charts will need to be unarchived before auditing or printing for access to all documentation.

a. From HBC Admin Console:

1. 1. Select the patient whose chart you wish to access by clicking the patient ID.
   2. If the chart has been archived, you will see “Archived” or “Superarchived” in red under the patient name.
   3. Click the “Unarchive patient now” button to the right.
   4. This will allow you to view/print all unarchived documentation when you log back into this patient chart in HBC/HBM.
   5. After you have finished with the unarchived chart, select the “Archive patient now” or “Super archive patient now” button to return the chart to its archived state to prevent speed reduction for the field staff.

2. Viewing and Printing

1. In the patient chart, click View Entire Chart icon in the top toolbar of HBC, the view patient history option in HBC Admin Console, or the view patient history option in the right drawer of mobile.
2. This will display multiple options for viewing the chart. There are several formats (ie chart order) to choose from
3. Enter all criteria and hit submit.
4. The selected format and date range will appear either expanded (to view/print all) or collapsed (to expand only the areas you wish to view or print) * For more detailed instructions see Tip Sheets “Print Chart App” and “Surveys and ADR Requests”

Note: If you need to view the entire chart or a large portion of the chart, it may be too large to open. If this is the case, you will receive a notice on the screen that a link will be sent to your email. Support will send you a link to the chart or portion of the chart you requested.

1. You will receive the chart from the selected date range to the current date. (If it is 5/10 and you request the chart for 4/1-4/30, you will receive the chart from 4/1-5/10)
2. You will also receive all the Initial documents and Comprehensive Assessments even if those visits occurred prior to the date range you requested for the chart to be printed.
3. When you receive the link and click on it, it will view as one large electronic document. Print out on paper if necessary.

Note: mumms highly recommends you familiarize yourself with the options available for printing and/or reviewing charts. Some formats are best for ADRs; others are better for surveyors, and other purposes.