Quality Improvement Study
|
Title of study: Evaluation of clinical documentation for diagnosis of depression |
|
Study Timeframe: Data collection AY 2003, Data evaluation Summer 2003, Data report Fall 2003 Implement Beck tools, possibly Fall 2003 Restudy and report results May 2004 |
|
Problem Statement: Staff concern re inadequate documentation of clinical signs and symptoms of depression on initial intake and first follow up visit. High risk diagnosis for suicide and possible litigation. |
|
Problem Measurement: (frequency, severity and/or source) 365 visits for depression AY 2002-2003 DSM Criteria for major depression used to evaluate completeness of documentation on 35 retrospective records from various providers AY 2003. DSM requires 5 or more of a list of a list of 9 symptoms plus 1)impairment in functioning or significant distress, 2)symptoms not due to physiological effects of substances or a general medical condition and 3)symptoms are not accounted for by bereavement |
|
Findings/Results: 35 Charts reviewed from various providers Initial Visit Documentation of 5 or more symptoms present in 17 charts (48%) Documentation of other 3 criteria present in 31 charts (88%) Follow Up Visit Documentation of 5 or more symptoms present in 7 charts (20%) Other criteria not measured once diagnosis established Analysis Providers are not adequately documenting symptoms to validate diagnosis or in providing follow up care. |
|
Measures taken to resolve problem: Implement use of Beck Inventories for diagnosing symptoms. Consider use of flowsheet or Beck for follow up visits. |
|
Recommendations for re-study: 35 charts AY 2004 to be reviewed using same criteria |
|
Problem Improvement/Change: |
|
Date reviewed and approved by Quality Committee: |
Adm.
QI Study Form, Created 7-11-03