Are You Overdocumenting? Techniques for Streamlined EHR Usage

Description

Learning Objectives

• Describe three of the five elements that make a condition reportable and ways nutrition documentation can help support.
• Identify at least two key reasons for reducing over-documentation in Electronic Health Records (EHRs), to improve clarity and utility of medical records.
• Describe at least two strategies for eliminating unnecessary information in EHRs to highlight patient’s essential clinical nutrition care for the inter professional team.

Performance Indicators

• 1.2.6 Provides accurate and truthful information in all communications.
• 3.3.3 Identifies opportunities for shared benefit and vision 4.2.8 Challenges, encourages and supports others to take action to advance the profession.
• 11.3.10 Effectively documents and communicates nutrition assessment findings and nutrition diagnoses.

Speakers

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  Jody Dragon

  Clinical Dietitian and Dietetic Intern Coordinator, John Muir Health

  Jody Dragon has dedicated over a decade to John Muir Health in the San Francisco Bay Area as a clinical dietitian, where she has played a pivotal role in enhancing patient care through nutrition. With a passion for education and mentorship, Jody has served as the Dietetic Intern Coordinator for the past six years, guiding and shaping the next generation of dietitians. At John Muir Health, Jody is celebrated for her leadership, having spearheaded a charting quality improvement project across the health system involving approximately 30 dietitians. Through mentoring interns, she identified the critical need for improved documentation practices, foreseeing their profound impact on patient outcomes and operational efficiencies. Jody has proactively acquired expertise in building charting templates within Epic through self-study and is committed to leveraging her knowledge to advance the field of dietetics.
  
  

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  Erin Trznadel

  Lead Clinical Quality Documentation Specialist, Northwestern Medicine

  Erin Trznadel is an accomplished and driven Lead Clinical Quality Documentation Specialist with 7+ years of experience in the field of Clinical Documentation Integrity and 23+ years nursing experience in a variety of clinical settings with the majority of the time being spend in the Emergency Department. For the past 7 years, she had led Northwestern Medicine’s Northwest Region Clinical Documentation Integrity Team to improve provider documentation to ensure accurate reflection of a patient’s clinical course, care received, and outcomes. Through collaboration with the Inpatient Clinical Nutrition Team, Erin have used her knowledge of documentation and coding requirements to improve the Epic documentation used by providers to capture nutritional diagnoses completely and accurately to improve quality, mitigate denials, and maximize reimbursement. Erin will continue to use her knowledge and expertise to advance the field of Clinical Documentation Integrity.

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Moderator

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  Ami Patel

  Director, Nutrition Services, UCSF

  Ami Patel is a versatile dietitian leader with over 20 years of various roles at University of California, San Francisco Health. In her current role as director for nutrition services, she is passionate to elevate the dietetics practice and link it to clinical outcomes. She and her team of CNMs have partnered with the internal EMR to streamline documentation and engage the data analytics team to develop dashboards that help clinical nutrition services aggregate key performance indicators and use them to identify staffing and resource gaps. She takes pride in supporting the UCSF dietetic internship using best practices and has personally trained nearly 200 interns.

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