Charting Quality Assurance

Question: I am looking for a tool I can use to improve quality assurance in my physicians’ charting, especially updating their problem lists. Do you have a suggestion?

Answer: I suppose my response would depend on what process you use now, and I’d like to know why your physicians aren’t updating their problem lists.

For example, nursing staff may be able to update the list for them at intake, so physicians would just have to add what is revealed in the exam.

Do they use a superbill to designate ICD-9s? If they update there, they can go back to the chart later.

Do they follow a template for documentation? If there is a printed document that has a field for the problem list, they may be prompted to fill it in.

If you are using EMR, of course, the system can prompt them to review the current list and do updates.

Take a look at your current process to figure out where the speed-bump is.