For the past year, I have served on the National Leadership Board of the Association for Healthcare Documentation Integrity (AHDI). AHDI may not be familiar to you, but it may ring a bell when I tell you that they were formerly the American Association for Medical Transcription (AAMT). AAMT became AHDI about six years ago when the association broadened its mission and vision beyond traditional healthcare documentation roles. Now AHDI’s focus is on the integrity of healthcare documentation, regardless of where it originates or is ultimately stored.
I think AHDI was smart to include the word “integrity” in its new name because it reminds us that the documentation accompanying patient care must adhere to standards of consistency, accuracy, and completeness. Integrity is important in all aspects of healthcare delivery, from the patient/caregiver relationship through coding and reimbursement practices.
Over the years, our clients who use 3M VoiceScript, ChartScript, and ChartScriptMD Software have taught me a lot about building integrity into each document. The best possible result is achieved when all ingredients are present and carefully considered. However, in today’s EHR-centered environment, what used to be recorded as an all-inclusive paper or electronic document may now be recorded in multiple fields or sections, by multiple contributors, and at multiple different times. As technology, new regulations, and other factors continue to impact how the healthcare industry creates and processes documentation, it is important that we consider the attributes necessary to ensure that integrity permeates all forms of documentation.
What features contribute to healthcare documentation integrity?
- Structured data elements: The patient demographics, as well as visit, order, procedure, and exam data are usually stored in data fields that are shared across multiple systems, which presents a challenge in ensuring that the information stays consistent, accurate, and complete as it moves among systems, contributors, and editors. Another challenge to integrity is in ensuring that all of the data elements needed for a specific document type can be available and viewable simultaneously in the EHR so that the caregiver, coder, etc., can see the information they need without having to dig for it.
- Organization: Documentation is most useful when there is a “place for everything and everything in its place.” Of course, in this case “everything” isn’t the right word, because too much data and narrative is unnecessary and inefficient. The individuals who use the documentation can provide practical input on where, when, and how the information is used. However, it can be challenging to agree upon a layout or methodology for certain document types when multiple individuals who use the same document have conflicting needs and opinions. The most prominent potential conflict I can think if are the documentation needs and preferences of caregivers versus the needs and preferences of coding and billing staff.
- Context: If data elements are the building blocks of a patient’s record, the narrative details of the patient’s history, living situation, and other personal and environmental factors are the mortar that constructs a more comprehensive and unique story. A broader context enables caregivers to tailor the care provided to the patient rather than a one-size-fits-all approach. As document capture methods become increasingly automated and abbreviated, organizations are challenged to ensure that the circumstances surrounding the patient’s situation are not lost in the shuffle.
Although I point out several challenges to documentation integrity, I don’t have any easy solutions. I think these challenges are an opportunity for healthcare organizations to determine the elements of integrity that they value and how they will resolve challenges so that the documentation they capture reflects the true experience of the patient, as well as the values and character of the caregiver and the healthcare organization.
Jill Devrick is the AHDI President-Elect and a Product Solutions Advisor with 3M Health Information Systems.