North Texas Research Forum 2025
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Division
North Texas
Hospital
Medical City Arlington
Specialty
Internal Medicine
Document Type
Poster
Publication Date
2025
Disciplines
Internal Medicine | Medicine and Health Sciences | Quality Improvement
Abstract
Introduction: Medicare beneficiaries who received an annual wellness visit (AWV) were noted to have reduced Medicare spending. Review of Medical City North Hills Internal Medicine Clinic data showed that 44% of eligible patients received an AWV. Improper documentation and coding were the primary reasons eligible AWVs were not accounted for even though they were performed. Majority of incomplete documentation was missing information regarding patient’s functional ability, level of safety, home safety, and activities of daily living. The information is normally obtained from a questionnaire completed by the patient prior to the visit. Questionnaire was noted by residents to be unorganized and contain extraneous information. The goal of the QI project is to improve resident documentation via revision of patient questionnaire. Methods: The original questionnaire was first examined and compared to the electronic medical record template used for AWV. Extraneous questions were removed and remaining questions were reorganized into respective categories of functional ability, level of safety, home safety, and activities of daily living. Draft questionnaire was reviewed by front office staff and sent to HCA Healthcare administration for final approval. Revised questionnaire was implemented February 2024. Proper documentation of AWV since implementation of questionnaire is currently being evaluated on a monthly basis. Individual AWVs will be reviewed to ensure documentation of the mentioned categories is included in the visit. Compliance rate will be calculated based on number of properly documented AWVs out of total AWVs that month. Results: Data regarding compliance with new questionnaire is currently being collected. Discussion: Low AWV rate at the Medical City North Hills clinic is due to multiple factors. Incomplete documentation by residents, improper use of billing codes, and limited familiarity with clinic EMR are some examples. Improvement in documentation rate should be ideally achieved through first fixing and optimizing the questionnaire so that the information can be input easier.
Original Publisher
HCA Healthcare Graduate Medical Education
Recommended Citation
Yeung, Chak Lam; Subramanyam, Gurunath; Ramesh, Krishna; Nadim, Mohammad; Bowser, Jasmyne; and Sturgeon, John, "Improving Annual Wellness Visit Documentation in Clinic" (2025). North Texas Research Forum 2025. 72.
https://scholarlycommons.hcahealthcare.com/northtexas2025/72