Charting the Path to Better Patient Care

2 months ago
Health care providers strive to deliver the best care to their patients. This video explains how understanding the performance of the health care system starts with ...

English subtitle

Hi, I’m Doctor 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 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.
When you see a patient, you’re gathering
information about symptoms, medical history
and pre-existing conditions.
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.
CIHI uses these codes along with other information
from the patient’s chart to provide comparable
and actionable data, so that healthcare providers
and organizations like yours can measure and
improve the way we deliver healthcare in Canada.
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.
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.
After Larry is discharged, your hospital’s
health records team assigns ICD and CCI codes
based on what you documented.
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 calculations 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.