Team # 1003 -- Weight Documentation with Significant Disease Diagnosis
ObjectiveWeight is an important contributing factor to the development, progression and management of many diseases. This study will evaluate if weight is documented in the chart at the time patients are seen for a primary diagnosis of Diabetes Mellitus, Fatty Liver, Hypertension, Metabolic syndrome (Polycystic ovary syndrome) and Obesity.
- Ann Shallcross, Leader
- Lisa Witt, Member
Results Achieved to Date
The goal is to have a weight documented on 95% of charts at that office visit.
Data will be measured, analyzed and reported to the UHS QI Committee in Fall 2011 and Spring 2012.
- Team Update
Weights are not being checked at intake consistently. Review of the data from October 2011 reveals that no one diagnosis is responsible for consistent under documentation of weights.
Reminder to nursing staff to get weights if appropriate to the diagnosis.
Clinician visits with the designated diagnoses from 3/18 to 4/14/2012 were reviewed for presence of a weight/BMI at that visit or within the month prior. Eighty five charts were reviewed of which 64 (75.29%) were compliant. This is actually a decrease from the initial review. Weights documented in the objective of the clinical note after the initial vital signs documentation cannot be captured by a computer generated report. This may account for some of the discrepancy. Again with the spring review, no one diagnosis was consistently associated with lack of weight documentation. Eating disorder diagnoses have the highest rate of compliance.
Reminder to nursing staff/ volunteers to get weights if appropriate to the diagnosis. Fall 2012 re-measurement.
June 8, 2012
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