Facility redevelops an assessment tool to ensure documentation

In January 2007, the University of North Carolina (UNC) Hospitals in Chapel Hill implemented a standardized, electronic assessment tool to aid its case managers in providing thorough and consistent patient assessments.

Beverly Wagner, RN, BSN, CCM, ACM, clinical care management educator at UNC Hospitals, and colleagues developed the tool with staff members to ensure their buy-in. The result was the brief assessment tool (BAT). The BAT made documentation easier and more consistent; patient assessment documentation rose immediately. “We had a nice surge from about 8% of discharges having measurable assessment documentation to about 30%,” says Wagner. “But we kind of hit a plateau there.”

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