Aims and Goals

The aims and improvement goals of this project were to:

Improve provider awareness of appropriate documentation through a provider education handout and follow-up group discussion. We provided this education in August to September 2015, and an additional education with revision to the International Classification of Diseases, Tenth Revision (ICD-10) in January to February 2016.

Fully redesign and standardize the provider documentation process building from the native Epic-based software.

Create a comprehensive neonatal provider documentation system including the history and physical (H&P), progress note, and discharge summary that utilizes sharing and collaborative maternal and neonatal data entry by clinicians or staff in the obstetrical and neonatal work environments.

Improve provider care documentation as reflected by hospital 3M severity of illness (SOI), risk of mortality (ROM), and case mix index (CMI) scores. We did not have any target goals to increase diagnosis documentation, but rather sought to improve accuracy of documentation.

Achieve these goals without a negative perception of the new documentation process by the provider. This would be measured by time-based study by one provider and group survey after completion of the study.