Dr. Agnes Berlin of AdventHealth Kissimmee (“AHK”) has been leading efforts to improve clinical documentation for Pioneer Medical Group. As a hospitalist and key member of the AHK Medical Executive Committee, Dr. Berlin has leveraged her clinical and administrative acumen to design numerous methods for documentation standardization.
Most recently, she designed a “Hospitalist Course” section within the clinical notes that succinctly summarizes major updates on a patients’ daily progress throughout their hospitalization. This tool streamlines transition of care between physicians and hospital departments.
Dr. Berlin and her team recommend the “Hospital Course” section on clinical notes be placed after “Assessments” as it would summarize the patient’s course and/or complications relative to their diagnosis. In addition, her team suggested that the summaries can be reported weekly, rather than daily, for patients with an extended length of stay.
Hopefully, through the implementation of this section and other standardization initiatives, such as the sharing of auto texts (importable text phrases) on clinical notes in the West Florida Division, Pioneer can improve on time management and risk stratification, reduce readmission rates, and ultimately enhance patient care.
