BEST PRACTICES FOR DOCUMENTATION AND
COMMUNICATION
FRIDAY/2:45-4:15PM
ACPE UAN:
0107-9999-17-026-L04-P
0.15 CEU/1.5 hrs
Activity Type: Application-Based
Learning Objectives for Pharmacists: Upon completion of this CPE activity participants should be able to:
1. List the key components that should be included when documenting a patient encounter
2. Review and discuss electronic medical record strengths and weaknesses in relation to pharmacist
documentation
3. Discuss the role of documentation in evaluating clinical impact on disease state management
4. Discuss communication styles and need to build rapport with various members of the healthcare
team including the patient
5. Review documentation and communication dilemma seen in nontraditional practice models
Speaker: Tim Brown, PharmD, BCACP, FASHP
Dr. Tim Brown is employed by Cleveland Clinic Akron General as Pharmacotherapy Specialist in the
Family Medicine Residency Program. He received his doctorate from Campbell University School of
Pharmacy with residency training at the Medical College of Virginia. Currently, he acts as a preceptor
for pharmacy and medical students and is a Professor at the Northeast Ohio Medical University.
Recently, Tim was awarded the Distinguished Service Award in Ambulatory Care by American Society
of Health System Pharmacists (ASHP). He has received the Golden Apple Teacher of the Year Award
multiple times and was awarded the William C Kelly Safety Leadership Award by the Ohio Hospital
Association. Dr. Brown served on the Board of Directors for Project Learn of Summit County and the
Community AIDS Network and was the Chair of the Specialty Council on Ambulatory Care Pharmacy.
He is the co-editor of two books on building a practice model in an Ambulatory Care setting, as well
as co-creator of PACT, an outpatient intervention tracking application. He is a past president of Ohio
Society Health System Pharmacists and past Chair of the Section of Ambulatory Care Practitioners of
ASHP. He was awarded Fellow status by ASHP in 2012 and serves on their Board of Directors.
Speaker Disclosure: Tim Brown reports no actual or potential conflicts of interest in relation to this CPE
activity. Off-label use of medications will not be discussed during this presentation.
2/6/17
“Best Practices” For Communication
and Documentation
Tim Brown, PharmD, BCACP, FASHP
Director of Clinical Pharmacotherapy in Family Medicine
Cleveland Clinic Akron General
“How to Talk the Talk
and Walk the Walk”
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Disclosure
•Co-Editor
of “Building A Successful Ambulatory Care Practice: A
complete guide for pharmacists.”
•Co-Creator of App called “Pharmacy Ambulatory Care Tracker
(PACT).”
Learning Objectives
Upon successful completion of this activity, participants
should be able to:
1.
2.
3.
4.
5.
Discuss communication concepts that help build rapport with
various members of the healthcare team.
Review documentation and communication dilemma seen in
practice models.
List the key components that should be included when
documenting a patient encounter.
Review and discuss electronic medical record strengths and
weaknesses in relation to pharmacist documentation.
Discuss the role of documentation in evaluating clinical impact
on disease state management.
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Definition of Communication
The imparting or interchange of thoughts, opinions, or
information by speech, writing, or signs
• 93% of communication is non-verbal which includes body
language, attitude, and tone
• 7% are actual spoken words
• 70% of your total waking time is spent communicating
•
• 16% reading
• 9% writing
• 30% talking
• 45% listening
Lack of Communication
Leads to faulty and incomplete exchange of information
• Causes oversight of potential red flags and clinical
discrepancies
• Increases risk for medical errors
• Potentiates sentinel events leading to injuries and
possibly deaths
•
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Common Barriers
• Personal values and
• Differences in language and
•
•
•
•
•
• Differences in schedules and
•
•
•
•
expectations
Personality differences
Hierarchy
Disruptive behavior
Culture and ethnicity
Generational differences
Gender
Historical inter-professional and
intra-professional rivalries
Differences in accountability,
payment, and rewards
Concerns regarding clinical
responsibility
jargon
professional routines
• Varying levels of preparation,
qualifications, and status
• Differences in requirements,
regulations, and norms of
professional education
• Fears of diluted professional
identity
• Complexity of care
• Emphasis on rapid decision
making
Personality of Communication
Aggressive
• Passive
• Assertive
•
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Aggressive Personality
• Communication Skills
• Closed minded
• Poor listeners
• Cant see others point of view
• Interrupts/Monopolizes conversation
• Beliefs
• “Everyone should be like me”
• “I am never wrong”
• Characteristics
• Achieve goals at other’s expense
• Bully
• Patronizing and sarcastic
• Behaviors
• Put down
• Do not think they are wrong
• Bossy
• Overpowers
• Know it all
• Doesn’t show appreciation
• Feelings
• Angry
• Hostile
• Frustrated
• Impatient
• Nonverbal Cues
• Point fingers
• Frown
• Glare
• Loud tone rigid posture
• Verbal Cues
• “You must”
• “Just do it”
• Verbally abusive
• Problem Solving Mechanisms
• Must always win a argument
• Operates in a win/lose
paradigm
Passive Personality
• Communication Style
• Indirect
• Feelings
• Powerlessness
• Always agrees
• Wonder why they do not get credit
• Doesn’t speak up
• Hesitant
• Others are better
• Beliefs
• “Don’t express true feelings”
• “Don’t make waves”
• “Don’t disagree”
• “Other have more rights”
• Characteristics
• Apologetic
• Behaviors
• Avoid conflict
• Asks permission unnecessarily
• Complains instead of taking action
for good work
• Nonverbal Cues
• Fidgets
• Nods head often and smiles
• No eye contact
• Low volume
• Verbal Cues
• Monotone voice
• Problem Solving Mechanisms
• Avoid and ignore the problem
• Withdraw from the situation
• Have difficulty implementing plans
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Assertive Personality
• Communication skills
• Feelings
• Effective, active listener
• Enthusiastic
• States limits/sets expectations
• Even tempered
• Does not judge
• Considers other’s feelings
• Beliefs
• Positive
• Nonverbal Cues
• Open and natural gestures
• Believes all are valuable
• Direct eye contact
• Handle all situations as best as possible
• Relaxed
even if they do not win
• All have rights and opinions
• Characteristics
• Self aware
• Trust themselves and others
• Open and flexible
• Proactive
• Behaviors
• Fair/consistent
• Action oriented
• Vocal volume appropriate
• Verbal Cues
• Use “I” statements
• Ask for options
• Problem Solving Mechanisms
• Negotiate, bargain and trade
• Confronts problems as they happen
• Do not let negative feelings build up
Split Personality Disorder
Not all situations conform to assertive style
• Aggressive style may be required when an action is
needed quickly ie emergencies
• Passive style may work for:
•
• Minor issues
• When conflict is greater than the problem
• Emotions are running high and cooling off period is needed
• The ultimate decision is out of your hands ie legal or gov’t policy
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TEAM BUILDING
Features of Effective Teams
•
Team leadership
• Coordinate tasks and daily work planning
• Develop team members
• Motivate and establish positive work environment
•
Mutual performance monitoring
• Understanding the big picture to achieve goals
• Able to step in if team member lapses or overloaded
•
Backup behavior
• Cross training
• Redistribution of workload
•
Adaptability
• Quick change to continue to provide quality patient care
•
Team orientation
• Overall goals align to provide best possible patient care
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Characteristics of an Effective Team
Respect and Trust
• Good communication
• Shared mental model or “Being on the same page”
•
WORKFLOW
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Workflow
Goal is to create a successful and sustainable practice
model that is high performing
• Model should be a complex adaptive system (CAS)
•
• Diverse individuals
• Interdependent connections
• Different levels of intensity
• May be inconsistent interactions
Workflow Optimization
•
Mindfulness
• Awareness of the system
• How your team members think, work, and respond
•
Meaningful interactions
• Conversation should move beyond information exchange
• Build relationships by eliminating variation in training and status
• Culture built on learning and action occur together
•
Dynamic construct
• Temporality
• Aggregation of actors and actions
• Context that constrains and enables actions
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Workflow Optimization
•
Areas of variability
• Staffing
• Clinic Pace
• IT needs
• Computer access
• Access to clinical data
•
Evaluation
• Constant scrutiny
• Problem solve quickly
• Adapt to needs of team including the patient
Workflow Optimization
•
Patient Flow
• Collect pt info once within process
• Minimize movement of pt
• Use EBM to assist in disagreement in pt management
• Eliminate unneeded or excessive activities
• Eliminate duplicative communication
• Provide clear and concise communication to the pt
•
Joy vs Burnout
• Pre visit planning
• Pre visit laboratory testing
• Sharing documentation requirements
• Specific pt care delegated to team members based on scope of
practice
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TEAM FLOW
Improve Communication
•
Team huddles
• Spontaneous
• Planned
•
Use technology
• Secure texting
• Patient portals
• Shared EMR notes
• Access to clinical data
•
Health information exchanges
• Secure exchange of patient information
• TOC planning between models
• Expanding your team beyond the four walls of your space
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Methods of Communication
•
Face-to-Face
• Advantages: Allows conversation, building of relationships, nonverbal
communication, immediate answers, can be indepth
• Disadvantages: Time consuming, inefficient, disruptive to pt care, and only
works if physically close, no recorded documentation
•
Phone or Page
• Advantages: Possible to get immediate answer, opportunity to elaborate,
collegial since person to person
• Disadvantages: Connecting, intrusive, unresponsive, limited
documentation
•
Fax or VM
• Advantages: Record of communication and nonintrusive
• Disadvantages: Confidentiality, no personal interaction, no discussion,
open for misinterpretation, increased workload to scan, delay in response
Methods of Communication
•
Electronic Messaging
• Advantages: recorded, nonintrusive, convenient, quick response
• Disadvantages: Security, no personal interaction, limited discussion,
misinterpretation, access/utilization by older population
•
Team huddles/Meetings
• Advantages: Collegial, nonverbal cues, immediate answer, in-depth,
efficient, confidential, inclusive of all team members, adaptive
• Disadvantage: Same location, time constraints, multiple agenda
•
EMR
• Advantages: Accessibility, written record, secure, electronic
communication, legally protected, data retrieval
• Disadvantages: No discussion, record is permanent, large amount of
information, easy to “lose” data, limitation with workflow, cumbersome?,
not built for pharmacists,
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WORKSHOP
Your Turn to Make this Information
Come Alive
Communication
•
Table Assignment:
• Determine who each of you are at your table
• Director
• Clinical Coodinator
• Clinician in pharmacy only model
• Clinician in a physician office
• Learner
• Create a Sphere of Influence
• What are the goals of your practice model
• Using the diagram provided outline those that impact your goals
• Trade with the person across the table from you
• Discuss similarities and differences
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Communication
Communication Shutdowns Exercise
• At your table there is a list of 25 statements that can have
the potential to end further discussion on any topic.
• Review these and then discuss your experiences with
others at the table
• Discuss how you have overcome or redirected a
conversation if one of these statements is made
• Brainstorm communication “saves” to keep conversation
on track
•
DOCUMENTATION
“If it isn’t in the chart it never happened!”
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Documentation
“A pharmacist acting under a consult
agreement shall maintain a record of
each action taken for each patient
whose drug therapy is managed under
the agreement “
http://codes/ohio.gov/org/4729.39v2
Documentation Facts
•
If you didn’t document, you didn’t do it
• Communication with other team members
• QI and risk reduction
• Competency
• Accountability
• Reimbursement
Determine policy for documentation within your practice
model
• Documenting may require credentialing and/or privileging
• Need IT and Billing advocates
•
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Documentation Facts
• General Principles (CMS) for your charts-• Medical record must be complete and legible
• Documentation of encounter must include:
• Reason for the encounter and relevant history, physical, and
prior health examination results
• Assessment, clinical impression, or diagnosis
• Plan for care
• Date and legible identity of the observer
Documentation Facts
•
If not documented, the rationale for ordering diagnostic
and other ancillary services should easily be inferred.
•
Past and present diagnoses should be accessible to the
treating and/or consulting physician.
•
Appropriate health risk factors should be identified.
•
The patient’s progress, response to and changes in
treatment, and revision of diagnosis should be
documented.
•
CPT and ICD-9-CM codes reported on the bill should be
supported by the documentation in the medical record.
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Key Components for Billable LOS
•
History
• CC –chief complaint in the patient’s words
• HPI –history of present illness
• ROS –review of systems; inventory of patient signs and symptoms
• PFSH –past (medical), family and social history
•
Examination
• Dependent upon clinical judgment and nature of presenting
problem
•
Medical Decision Making
• Moderate problem –1 or more chronic illnesses with mild
exacerbation
• Minimal diagnostics –reviewing or ordering labs, EKG, PFTs
• Moderate management –prescription drug modification, negatives
“count”
Documentation Standards
•
Medication History
• Patient’s past medication use and related health problems
• All current medications including adherence
• Medication-related allergies with ADRs
•
Active Problem List with Assessment
• Current health conditions and status
• Medication-related problems
• Preventive measures needed/completed
•
Plan of Care to Optimize and Improve Patient Outcomes
• Disease state management plan
• Medication therapy plan
• Collaborative plan for follow up and monitoring
Pharmacotherapy 2014;34:e133-148
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Electronic Medical Record
Not built for Pharmacists
• Adapt to fit your model
• Usually cannot create template yourself
• Need to map your workflow
• For your visit what documentation is NEEDED
• Create a workflow template
• Use screen shots
•
Create shortcut ie dot phrases in EPIC
• Engage IT to build it
• Limit access to pharmacists
•
WHERE TO START
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HPI
Type
Description
Example
Duration
How long has the pain
been there?
Days, months,
years
Severity
Pain scale
1-10
Quality
Description
Burning, aching
Context
When did the pain
begin?
Suddenly, over 3
months
Modifying factors
What makes it better or
worse?
Heat, ice,
elevation
Associated signs
and symptoms
Are there any other
symptoms with your
problem?
Numbness,
swelling,
constipation
Timing
When does the pain
occur?
With exercise, with
sitting
HPI Example
HPI
Ø45
year old female lung
cancer patient complains
of intermittent sharp pain
in her left hip after fall
from bed . Additionally,
she complains of left leg
numbness; describing the
pain as a 9 on a scale of
1-10. She states aspirin
has not relieved this pain.
Criteria
ØLocation = Hip
ØDuration = today
ØTiming = intermittent
ØSeverity
= 9 (scale 1-10)
ØQuality = sharp pain
ØContext = falling from
bed, lung cancer
ØModifying Factor = aspirin
ØAssociated S&S = pain,
numbness in leg
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ROS
Negatives count
• Constitutional – vitals, appearance
• Psychiatric – depressed, insomnia, sad, upset
• Cardiovascular – chest pain, palpitations
• Musculoskeletal – myalgia
• Respiratory – SOB, cough, orthopnea
• Endocrine – polyuria, polydipsia, polyphagia, S/S thyroid
•
GI – diarrhea, N/V
• Eyes – vision disturbed, blurry
•
ROS Tips
•
A problem pertinent: ROS identified, through a series of
questions, inquiries about the system directly related to the
problem
•
Extended ROS: must identify the positive responses and
pertinent negatives for at least (2) and not more than (9)
systems
•
Complete ROS: must evidence documentation of ten organ
systems. The attending physician may use “All other systems
negative” when (2) pertinent positives and/or negatives are
documented.
•
If unable to obtain, document why
• mental state
• language barrier
• IDD/MRDD
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PFSH
• Outline of what to document
• PAST: Pt’s past experience with illnesses, operations, injuries,
medications (prescriptions, herbal, OTC), allergies, and
treatments.
•
FAMILY: Medical events in pt’s family that pose a risk to the pt
and/or are related to the current illness or chief complaint.
•
SOCIAL: Age appropriate review of past and current activity,
including marital status, employment history, sexual history,
living arrangements, smoking (primary and secondary), drinking,
or exposure to environmental toxins.
PFSH
•
Pertinent:
• At least one from any of these areas
•
Complete:
• For established patients in the office at least two of these
• For new patients or TOC all three are necessary
•
Can state that it is unchanged
• Caution this cannot appear in every single visit
•
Do not state that PFSH is “non-contributory”
• “Negative” is an acceptable response
•
Documentation from entire team
• The billing provider must refer to it or sign and date
documentation by others.
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PE
Constitutional – weight loss, appearance, vitals
• Cardiovascular – JV distension, heart sounds
• Respiratory – lung sounds, Asthma Control Test
• Psychiatric – MMSE, PHQ9, affect
• Skin – intact, bruising, wounds not healing
• ENT, GI, Genitourinary, Musculoskeletal, Neurologic and
Hematologic/Lymphatic can also be examined
•
•
Minimum of two for higher level billing
Complexity-Medical Decision Making
Type of Decision
# of Dx or
Management
Options
Amount &/or
Complexity of
Data
Risk of
Complications,
M/M
Straightforward
Minimal
Minimal or None
Minimal
Low Complexity
Limited
Limited
Low
Moderate
Complexity
Multiple
Moderate
Moderate
High Complexity
Extensive
Extensive
High
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Established Outpatient Billing
Codes
99212
99213
99214
99215
History
Problem
Focused
1-3 HPI
Expanded
problem focus
1-3 HPI
1 ROS
Detailed
4 HPI
2 ROS
1 PFSH
Comprehensiv
e
1 HPI
10 ROS
3 PFSH
Exam
Problem
focused
1 body area
Expanded
problem
focused
2-7 body areas
Detailed
2-7 body areas
with detailed
exam
MDM
Straightforward
Low
Complexity
Moderate
Complexity
High
Complexity
Barriers to Pharmacists’ Billing
Many are allowed to bill at 99211 only
• No matter, continue to document what you do regardless
of how it is billed by the office or institution
• Can still track levels of intervention for internal purposes
to illustrate impact of pharmacist
• In some situations, you may be employed by a
progressive billing department
•
• Set up a meeting with billing first then administration
• Be ready to educate about pharmacy services today
• Bring literature outlining best practices and billing practices
• Bring example SOAP note of how you would document
• If you have metric outcomes now is the time to bring
to brag about them
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WORKSHOP
Your Turn to Make this Information
Come Alive
Clinical Template
Create a workflow using the components of
documentation from the presentation
• EMR
•
• Which EMR do you have in your office
• Type of patients you routinely see
• Build template for each type of visit
• Shortcut creation
• How do you share this documentation
•
Work within your limitations
• What are roadblocks
• Gaps in communication
• Documentation relationship to your billing
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Using your Template
•
ML is a 48yo ____________ presenting today for
____________.
•
HPI:
•
ROS:
•
Assessment:
•
Plan:
Assigments
•
Each Table choose one of the following for ML:
• Anticoagulation
• T2DM
• HTN
• Hyperlipidemia
• Polypharmacy MTM
• TOC visit
• AWV
• Migraine headaches
• Maintenance of sobriety
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Where does your patient fit?
Codes
99212
99213
99214
99215
History
Problem
Focused
1-3 HPI
Expanded
problem focus
1-3 HPI
1 ROS
Detailed
4 HPI
2 ROS
1 PFSH
Comprehensiv
e
1 HPI
10 ROS
3 PFSH
Exam
Problem
focused
1 body area
Expanded
problem
focused
2-7 body areas
Detailed
2-7 body areas
with detailed
exam
MDM
Straightforward
Low
Complexity
Moderate
Complexity
High
Complexity
THANK YOU
Any Questions
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