RESUMO
Competitive health care systems are improving their clinical and cost efficiency by performing clinical practice analyses. Large numbers of severity-adjusted cases provide the most objective data for making clinical efficiency decisions. The most cost-effective way to perform these analyses is to utilize well-coded, computer-based health information. This requires consistent coding of patients' comorbidities and complications as well as an interactive working relationship between coders and clinicians providing the clinical practice analysis. The article describes one hospital's evolving clinical efficiency information needs, how its health information system met them, the clinical practice analysis procedure, and the outcomes of this clinical practice analysis.
Assuntos
Sistemas de Informação Hospitalar , Serviço Hospitalar de Registros Médicos/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde , Indexação e Redação de Resumos , Controle de Custos , Sistemas de Apoio a Decisões Clínicas , Eficiência Organizacional , Hospitais com mais de 500 Leitos , Custos Hospitalares , Hospitais Rurais/organização & administração , Humanos , Prontuários Médicos/classificação , Serviço Hospitalar de Registros Médicos/normas , Mississippi , Índice de Gravidade de DoençaRESUMO
We developed and implemented an automated discharge summary process in a regional integrated managed health system. This multidisciplinary effort was initiated to correct deficits in patients' medical record documentation involving discharge instructions, follow-up care, discharge medications, and patient education. The results of our team effort included an automated summary that compiles data entered via computer pathways during a patient's hospitalization. All information regarding admission medications, patient education, follow-up care, referral at discharge activities, diagnosis, and other pertinent medical events are formulated into the discharge summary, discharge orders, patient discharge instructions, and transfer information as applicable. This communication process has tremendously enhanced information management across the system and helps us maintain complete and thorough documentation in patient records.