eStar update: Update to documentation deficiency process for outpatient encounters

Since eStar went live in November 2017, the documentation for outpatient encounters (office visits) has been tracked, but there has been no formal process for provider notification of deficient and delinquent documentation. Changes to this process are necessary as accurate and timely documentation of every patient encounter is essential to the delivery of excellent patient care. 

On Oct. 2, 2019, changes to the provider documentation deficiency process for Open Clinic Encounters (incomplete office notes) will go into effect.

If the Open Clinic Encounter has not been closed* within four (4) days of the clinic visit, an Open Clinic Encounter Deficiency will be triggered from eStar. The Open Clinic Encounter is considered delinquent if it is not closed within 14 days of the clinic visit, in accordance with the VUMC Documentation Standards for Providers (IM 10-20.13) policy.

The weekly Deficiency/Delinquency Provider Notification Letters (sent to the Deficiency Notification Letter folder of the provider’s In Basket) will be updated starting October 2, 2019 and will now include deficient and/or delinquent Open Clinic Encounters in addition to inpatient documentation tasks. These messages will appear in the Deficiency Notification Letter folder of the provider’s In Basket.

If the Open Clinic Encounter is not closed by 28 days, the provider becomes eligible for suspension of certain privileges as per policy. 

Open Clinic Encounters can be accessed in the Chart Completion folder.

Some providers encounter obstacles to closing encounters. Providers who experience such issues should contact their eStar Central Support Specialist or Erica Byrum (Erica.p.byrum@vumc.org).

*To close an Open Clinic Encounter in eStar, there must be a:

• Clinic Note
• Diagnosis
• Level of Service
• Signature

If any of these elements are missing, the Encounter remains open and a bill for service cannot be submitted.