Encounter Documentation Norms
What is it?
Clinical encounters occur in both inpatient and outpatient settings and are managed in Connect Care as a package of information related to a specific visit, admission, interaction or intervention. Key encounters (e.g., emergency or outpatient visits, admissions) must include appropriate documentation of information gathered during and communicated after the encounter.
Encounter documentation norms relate to minimum requirements for an encounter to be "closed" with appropriate documentation, or otherwise completed within an acceptable time frame:
An ED Provider Note must be completed and appropriately signed within 24 hours of a patient departure or transition from an emergency department visit.
An Admission History and Physical should be entered to Connect Care and appropriately signed for all inpatient encounters within 24 hours of admission, with provisions available for flagging a consultation note to serve as a H&P.
A Discharge Summary should be entered to Connect Care and appropriately signed for any inpatient encounter within 48 hours of the actual discharge/transfer time.
An Operative Report should be entered to Connect Care and appropriately signed within 24 hours of all major surgical events.
All outpatient encounters should be documented (note or letter), signed and closed within 3 days of an outpatient service event.
Why does it matter?
"Opening" and "Closing" encounters affects what other Connect Care users can see or do, especially in outpatient contexts. If, for example, a note is kept in a "pended" or incomplete state, it may not be possible for persons other than the author to view vitally important information. Accordingly, all Connect Care users need to manage encounters in a way that does not unduly limit access to information or functions needed by others.
Primary caregivers, as well as specialists participating in outpatient care, need to be aware of the actions and accountabilities of others. Their effectiveness is directly impacted when key documentation is missing or unsigned (or co-signed to validate trainee work) or delayed. Connect Core norms reflect the communication pace of modern practice, and the capacity of modern digital health records to keep pace.
Summative encounter documentation is the primary method for communicating plans and accountabilities across the continuum of care. Standardization of the content, format and timeliness of encounter documentation is the most powerful determinant of informational continuity.
The length of time between discharge and receipt of summative documentation correlates with increased risks for readmission and other post-discharge adverse events.
Alberta Health Services staff bylaws, as well as CPSA professional standards, set absolute outer bounds for encounter documentation timeliness:
ED Provider Note - within 24 hours of patient departure/transfer.
Admitting History and Physical (or linked consult) - within 24 hours of admission order signing.
Operative Note - within 24 hours of completion of major surgical event.
Discharge Summary - within 14 days of discharge.
Consult Letter or Note - within 2 weeks of an outpatient encounter, which must be signed (closed) within 3 weeks of the encounter date.
Who is responsible?
The healthcare prescriber designated as the responsible prescriber for an encounter is accountable for signing encounter documentation and closing encounter events.
ED Provider Notes - must be signed or cosigned by any of ED Attending Prescriber(s) who may have assessed or followed the patient during the encounter.
Admitting History and Physical (or linked consult) - signed or cosigned by the Admitting Prescriber for the encounter.
Operative Note - signed or cosigned by the Attending Prescriber or Lead Prescriber (if operating prescriber different from attending) for the event.
Discharge Summary - signed or cosigned by the Discharging Prescriber (attending prescriber at the date/time discharge).
Consult Letter or Note - signed or cosigned by the Encounter Prescriber.
Accountable prescribers received deficiency notifications via the Connect Care In Basket.
How is it done?
The only way to satisfy encounter documentation norms is to complete and sign the required documentation type within the appropriate time interval. A number of tools facilitate taking timely action:
Admission, Discharge and Transfer Navigators make this obvious by calling out the documentation requirement.
The Notes Activity allows a desired note type to be selected then authored.
The inpatient chart Sidebar has a "Notes & Sidebars" section (select from index at top of sidebar) with quick links for fulfilling these norms with a single click that sets up appropriate summative documentation using provincially standardized templates.
Connect Care standardized Patient Lists have columns displaying icons indicating needed documentation requiring co-signs.
Admission, Daily and Discharge Checklists (available in chart sidebars as a report attached to patient lists) highlight outstanding encounter documentation norms.
In Basket messages appear when encounter documentation norm time intervals have been exceeded.
Sharing before Signing
All of the above highlighted summative documentation types are shared with Alberta's Electronic Health Record (Alberta Netcare Portal, twice daily) and capable Community Electronic Medical Records (up to 4 times daily). Effectively, summaries are received the same day they are signed.
The trigger for sharing is document signing or (required) cosigning. To avoid duplicate document challenges in receiving systems, it is important that authors "Share" documents, leaving them to be "Signed" just once by the accountable prescriber. That there may be outstanding laboratory test results is not a justification of signing-then-re-signing encounter documentation. Rather the summary transition plan should specify who is accountable for following up investigations unreported at discharge.
How is compliance promoted?
Feedback about adherence to clinical documentation minimum use norms is provided to prescribers using In Basket charting deficiency messages. These focus on whether required summative documentation has been completed within expected time frames.
Select encounter documentation norms appear within Minimum Use Norms and Meaningful Use Norms dashboards, available in the Hyperspace "Dashboards" workspace. Metrics are added as they become available and validated for AHS contexts:
Discharge Documentation Timeliness
The Discharge Documentation Timeliness Entry Metric is the proportion of hospital acute care inpatient encounters where the a discharge summary is signed or (if required) cosigned by a responsible provider within 24 hours, 48 hours and 72 hours of the actual time of discharge from an inpatient facility.
Derivation of these metrics is explained further in the Connect Care Builder Handbook, with links to data quality definitions.