Your Job is Documentation

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By John Garrett

If you have been in medical imaging for more than a few days, you have probably heard someone complain about documentation. It is not uncommon for an imaging specialist to declare that getting the equipment repaired is more important than documenting the work. It is all about patient care after all. That sounds reasonable, but it misses the big picture. Documentation is patient care.

This is the medical field. Documentation is everything in every aspect of medical services. Recording that a bed was cleaned, the amount and time a specific drug was administered, wait times for access to a patient room, and all service performed on medical equipment is equally important for patient care. Documentation is concerned with patient care for all patients, not just the next patient.

Recording the details of the service performed, any vital measurements, and the nature of the service all add to the data base of knowledge for that equipment. It contributes to a larger body of information that can be used to calculate a number of important and useful insights. There are a number of items that this entered (or forgotten) information impacts in a well-run company/hospital.

Properly documented preventive maintenance (PM) and corrective maintenance (CM) allows the calculation of how often a type of equipment fails. This calculation can be used in a number of different ways. It can be calculated for the first three years out of warranty and compared to the fifth year and beyond to see if there is a significant increase in repair costs and down time. It can be used to calculate the need for more or less equipment. It can assist in calculations for more field service engineers (FSE) to ensure that there is enough staffing to provide adequate service. All of these items translate into better patient care. They also translate into more efficient use of the limited reimbursement dollars that a hospital receives. As those reimbursement dollars decrease or become harder to achieve, the value of documentation of service increases.

Detailed documentation can assist in calculating trends. Do you have significantly more service events at a specific time of day? Do you have more service incidents when a specific operator is using the equipment? Are you seeing problems after the monthly hospital generator test? For critical units, part failure trends can be used to minimize downtime by scheduling parts replacement prior to normal failure. These are only a few of the items that allow for an understanding of how to improve unit uptime and increase useful life.

“I don’t have time to complete documentation,” is a common statement made by many a FSE. The truth is, it is simply a paradigm shift. If the documentation is part of the job, the job isn’t complete until you have performed the documentation. Simply require the documentation to be completed prior to starting the next job. An FSE would not leave a job to start another without replacing the covers of an imaging system. The documentation should be viewed the same as leaving the covers off of a system. Once the new habit is developed, the payoff in the benefits of data and CMS compliance will be seen.

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