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There is no greater healthcare challenge than that of clinical information and documentation.  It is in the gathering and strategic use of accessible information about the patient, about care provided, and outcomes that we will be able to measure and improve efficacy of care. DUHS continues to be a leader in the implementation and progressive use of the Perinatal Electronic Medical Record (EMR).A Perinatal Informatics System is intended to provide all members of the healthcare team with comprehensive, accurate and timely information.

With the evolution of the Perinatal EMR in our setting, we have been able to automate our outcomes and QI reporting utilizing scheduled reports. Historically, the RN was held responsible for accurate documentation to meet existing Compliance and Safety Standards.  Chart audits were completed manually to evaluate compliance on an ongoing basis. The scheduled reports eliminate the need for cumbersome manual data extraction and/or duplicate documentation. 
These reports include provider and nursing rounding sheets, electronic delivery log, medication reconciliation, resident education validation, daily patient flow logs, and statistical outcomes data.  DUHS created these outcome reports to meet regulatory guidelines, business needs of the Health System and to use in benchmarking with other like organizations.

Maternal and Newborn data is extracted and populates fields in the scheduled audit reports. The platform is an excel format that readily supports ad-hoc queries or pdf format.  This has enabled us to support Health System trend analysis and business practices in both high and low risk settings, the academic medical center setting, and the community hospital. The statistical analysis reviews comprehensive maternal and newborn data, staff compliance with mandatory documentation, and validation of the continuum of care provided.  Ten years of historical data affords us the unique opportunity to visualize trends with spreadsheet, ongoing documentation for QI corrections, research to evaluate and change clinical indicators

A core interdisciplinary team outlined compliance standards. We developed and implemented a comprehensive education plan over a three-month period. Physicians, nurses, unit based leadership and IT actively participated in chart audits and provided feedback to individual staff.  This provides the care team a unique opportunity to view ongoing documentation.  Adherence to documentation standards is currently incorporated into the annual performance appraisal for staff. Primary outcomes include streamlined documentation for caregivers, increased staff satisfaction, availability of accurate maternal/newborn information across the continuum and increased accuracy of information for statistical analysis and reimbursement.