Discussion Board Prompt:
The interdisciplinary team in the XYZ facility was experiencing problems with the habilitative portion of the individual’s’ records in that direct care staff was not addressing changes in the program. Recommendations were being made on the quarterly team reviews but were not getting into the program records to be instituted by the direct care staff, as required for the continuity of care.
Jean Deaux, a health information management professional, was contacted about this discrepancy in the program. She noted the recommended program changes and that the revised program was not being carried out, along with the lack of some type of documentation to tie these two together.
After studying the problem and the frequency with which it was occurring, she made the following recommendation: The suggested changes were to be covered in an addendum format, so that any time throughout the year when a major change in the individual’s program was instituted, the change would be reflected in the 24-hour schedule, thus alerting the direct care staff of the addition, deletion, and/or change in the program.
To better track the documentation requirements, Ms. Deaux elected to monitor, in her monthly audit of the records, whether program changes were being documented appropriately and to submit any variance in the program to the assigned QDDP.
Who is the “assigned QDDP?” Why do you think Ms. Deaux elected to report variances to the QDDP?
How could electronic health records or electronic information systems have made a difference in this situation?
