Bob Luttman, Robert Luttman & Associates
(Briefly) Revisiting VMS Design Issues
Gateway Documentation - Normal Days
Gateway Documentation - Insert Days
Patient Documentation in the Gateway System
Now that we know what we need to know, how do we collect the data?
First, it is important to discuss patient documentation in general. We document patient care in order to provide a record of that care and to communicate with other care providers about that care. The latter is especially important when a variance occurs, especially a gateway or a critical variance.
Second, the documentation must not burden care providers. Again, this is especially true when major variances occur. A gateway variance is a sign that the patient needs more care, not more paperwork. This requires charting-by-exception and variance documentation that does not require separate forms.
The Gateway System accomplishes this by:
- Combining the pathway, variance documentation, other documentation requirements, and the progress note into one form.
- Using "insert" (or add-on) days when the patient's progress is delayed.
A MS Word template file is here, download it to create your own forms. Below is an example of a "normal" day documentation tool (click here or on the picture to see a full size version, then come back here):
Things to note here, and contrast with the traditional documentation model presented before:
- The progress note is merged into this document. Critical variances require detailed notes, detail variances require nothing. This facilitates communication between the care team to resolve variances.
- All variances are documented. If the task or outcomes is accomplished the shift it occurred is check. This eliminates the question of whether something is a variance or a documentation omission. Some tasks or outcomes have a Not Applicable check box in their text (first column).
- Everybody documents - to the greatest extent possible - on this form. The responsible discipline is noted for all tasks.
- Except for the flow sheet no other standard forms are required to document patient care.
This still leaves the issue of extended patient stay and gateway variance documentation. That is on the next page.
