Incomplete Medical Records: Policy, Considerations and Consequences
In November 2020, policy AD-HIM-020 Physician Incomplete Notification came into effect for all physicians in Nova Scotia. This policy mandates the completion of clinical documentation in the Patient Health Record.
Compliance with NSH Medical Staff Rules and Regulations
In alignment with the NSH Medical Staff Rules and Regulations, all Attending Physicians and dentists must complete any outstanding elements of a patient’s Health Record within ten days of discharge. This requirement is crucial for ensuring safe patient care and maintaining the accessibility of information for continuity of care.
Accurate and up-to-date Health Records are essential at the system level as they contribute to the measurement of health indicators provincially, including the Hospital Standard Mortality Ratio (HSMR). Incomplete records may lead to inaccurate and negative assessments of health outcomes in the Zone.
The College of Physicians and Surgeons of Nova Scotia also provide a Professional Standard for Medical Records.
Consequences of Non-Compliance
Nova Scotia Health requires complete discharge summaries within the timeline of 10 days after discharge.
Non-compliance with this policy will begin to result in the suspension of privileges by the Vice President of Medicine.
Notification to Attending Physicians
Health Information Services (HIS) will generate incomplete discharge summaries and operative reports for each Attending Physician twice a month. Physicians will receive a Physician Incomplete Notification letter detailing any incomplete clinical documentation.
Notifications will specify the names of patients with incomplete documentation and categorize them into the following time periods:
- 1 – 14 days overdue
- 15 – 29 days overdue
- 30 – 39 days overdue
- 40 or more days overdue
For the initial period, notifications will be sent via email, letter, and fax. Subsequently, HIS will transition to sending notifications exclusively to your Nova Scotia Health email address to streamline the administration of health records. If you do not have a Nova Scotia Health email address, please email leigh.smith@nshealth.ca to begin this process.
Did you know?
When a physician does not complete their medical charts to the standard of completeness and within a reasonable time, they may result in jeopardizing your CMPA coverage or leave you at unnecessary medico-legal risk?
Read more here: CMPA - "Dictated but not read": Unreviewed clinical record entries may pose risks (cmpa-acpm.ca)
Zone Deficient Medical Chart Summary Reports
The Medical Executive Directors, in coordination with Department Heads for each Zone, will oversee the policy’s implementation. HIS will provide Medical Executive Directors with bi-monthly summary reports on incomplete clinical documentation, detailing the physician’s name, the number of incomplete reports, and their respective overdue periods. Patient names will not be included in these reports.
Medical Executive Directors will forward these reports to Department Heads, who will then address the issues with the respective physicians.
Implementation
We recognize that adapting to new policies can be challenging. Should you need assistance with addressing deficiencies, Health Information Services staff are available at incompleterecords@nshealth.ca.
If you anticipate difficulties in completing your charts on time, please contact your Department Head or Zone Medical Executive Director for support and discussion.
September Greetings and Google Partnership - Message from the CEO
For many of us, September is the start of a new year. This is true for me, too. It’s also a time of introspection, as I reflect on my three years at Nova Scotia Health.
When I crossed the threshold into the corporate offices of Nova Scotia Health as interim President and CEO on September 1, 2021, I was embarking on a new journey. I leaned on you to help me lead our organization and transform healthcare in our province. In the early months, I followed advice from frontline staff and asked many questions from colleagues, and others took me deep into the metrics and data to truly understand where Nova Scotia Health was and where we needed it to be.
This journey hasn’t been for the faint of heart – we’ve overcome obstacles together. We remember, and endured, Omicron, natural disasters – fires, floods, snowstorms –all the while, maintaining consistent patient care and working to attract and keep valuable healthcare talent. This is the direct result of your hard work, perseverance, dedication, and innovation – it never stops. Thank you.
This morning the Government of Nova Scotia announced a strategic partnership with Google Cloud, a huge leap forward in our digital health transformation journey. You can read the press release here.
This partnership will support both physicians, care providers and Nova Scotians with AI healthcare solutions that will empower, improve care outcomes, and improve accuracy and efficiency.
These include:
- providing Nova Scotians advanced search capabilities with user-friendly language across health system resources, such as the YourHealthNS app and Nova Scotia Health websites; giving people faster, easier access to healthcare information, resources, and services.
- allowing healthcare professionals to use a natural-language search to locate relevant information in a patient’s health record; improving efficiency by reducing time spent searching through patient records and quickly provide clinicians with the information they need to help inform decision-making and ultimately improve patient outcomes.
- supporting radiologists with their review of chest X-rays by providing preliminary imaging findings, which will improve efficiency.
The goal in introducing tech-based solutions, like Google Cloud, to teams across Nova Scotia Health is to reduce time-consuming paperwork, giving your more time to for care, services, and more work-life balance.
Very shortly, we will send and invitation to watch Nova Scotia Health’s 9th Annual General Meeting. Where we’ll share and celebrate your successes and achievements from the past fiscal year – and lay the groundwork for what’s to come over the next few months.
Until then, with kind regards,
Karen
OPOR-CIS Video: “Why Now”
At the heart of the One Person One Record Clinical Information System (OPOR-CIS) design is a standardized approach to patient care that leverages technology to enhance outcomes and experiences across the province.
The new OPOR-CIS: Why Now? video brings together some of the hundreds of Subject Matter Experts (SMEs) from IWK Health and Nova Scotia Health who have contributed their time and expertise to the development of the OPOR-CIS to share their insights into how this clinical transformation will optimize care across Nova Scotia. View the video now.
Learn more about OPOR and the OPOR-CIS at opor.nshealth.ca.
Introducing the Co-Facilitators for the Behaviour Change Counselling Development Program!
We are thrilled to introduce Dr. Darya Kryzskaya and Dr. Jamie Johnstone, the dynamic co-facilitators of our Behaviour Change Counselling Development Program.
Dr. Kryzskaya, a family physician and faculty member at Dalhousie University, brings extensive experience from her clinical practice and her work with the Medical Council of Canada. Dr. Johnstone, a Halifax-based family physician with a background in rural medicine, is dedicated to collaborative care and teaching, with affiliations at both Dalhousie and Memorial Universities.
They will be co-leading the program with the team from Nova Scotia Health to help healthcare providers like you enhance your skills in behaviour change counselling. Join us to gain valuable insights and practical tools for supporting patients in making health behaviour changes.
Register here for this program that starts September 12th. For more information visit PHCQuality.ca.
Action for Health Key Messages - AUGUST
There is a lot happening in the health system. We know it can be hard to stay up to date. You can find timely and relevant highlights in the monthly Action for Health Key Messages series, which are posted on the Health Transformation Hub. The key message document provides updates, news, and announcements from the previous month related to Patient Care and Health Workforce initiatives as well as key data and metrics. Review this month’s key messages here: Action for Health Key Messages.
Read the full newsletter here.