Connect Care Clinical Documentation Deficiency Notices

Prior to Connect Care, clinical charting deficiencies were tracked and enforced through processes managed by Alberta Health Services (AHS) Health Information Management and zone Medical Affairs, with a focus on key summative documents required for all inpatient encounters. 

Minimum charting expectations are reinforced for Connect Care users through In Basket reminder messages that reflect Clinical Documentation Norms and Required Documentation. The reminders flag missing or incomplete History & Physical, Discharge, Operative or Emergency Provider notes, along with tools for rapidly addressing or redirecting deficiencies.

Starting mid-January 2022, Connect Care charting deficiency reports are additionally received and acted upon by zone Medical Affairs to ensure compliance with AHS Medical Staff Bylaws & Rules. Privilege curtailment warnings are addressed by each zone’s Medical Affairs office.

As charting deficiency reports include items dating back to the first Connect Care launch, many deficiencies may have accrued for users who have not attended to chart completion In Basket reminders. Prescribers can review and act on Connect Care charting deficiencies via the In Basket chart messages folder.