How do you know all of the elements are in place for high-quality healthcare documentation? Where is the “sweet spot” in which the people, processes, and technology come together to deliver the optimal mix of complete, accurate, and timely content? AHDI and AHIMA have identified seven contributors to documentation quality, all of which deserve careful consideration when designing a quality assessment program.
The Author: Physicians and other clinicians affect the quality of documentation more than anyone, or anything, else. Whether dictating or entering content directly, caregivers need to organize and articulate their thoughts so that the patient’s care, and the context around it, is clearly understood by the reader. Organizations need to have training and tools available to assist dictators with developing skills that enable them to follow standards and optimize the results being generated from their speech. Some challenges, such as pronounced accents, may always be present, but many bad habits can be improved or eliminated with practice.
Experience: No one starts out as an expert in their profession, but over time every individual, whether a physician or a healthcare documentation specialist, gains knowledge and skills through experience. To ensure optimal quality, organizations need to assign work to individuals with the appropriate depth and breadth of knowledge. Every person involved in the creation or review of healthcare documentation should be encouraged to further their professional development and build their skills so they can progressively perform work of greater complexity.
Research Tools: Both clinician authors and healthcare documentation specialists need to have access to industry-accepted professional references to enable them to verify terminology usage, drug interactions, standards of care, disease processes, and much more. These tools provide additional assurance that the documentation has been created carefully and accurately, allowing no excuse for guesswork or assumptions.
Quality-Enhancing Software: Similar to research tools, functions such as spell check can inherently enhance quality when they are built into the document creation systems being used. Other tools, such as text expanders and templates, can improve efficiency while also supporting accuracy. As technology advances, these tools will become more sophisticated and tailored to the author, editor, or reviewer’s needs.
Equipment: It doesn’t matter how competent the author or the healthcare documentation specialist is if the tools they use to create documentation do not function properly. One of the most common reasons for equipment problems is inadequate training. Thorough software and hardware training may be inconvenient, but it saves time and resources in the long run by promoting efficiency and standardized workflows. Dictation equipment, especially when shared by several dictators, must be maintained and replaced periodically to ensure good voice quality, acceptable volume levels, etc. In addition, the equipment needs to be used in an environment with minimal background noise to allow for clarity.
Patient Demographics: How do you solve a problem like Maria? Or is it Marie? Or Mary? Occasionally a document can be inadvertently linked to the wrong patient, and sometimes, even if it is the right patient, the document can be matched to the wrong encounter. Demographic issues, whether the information is missing, wrong, or incomplete, can cause delays, misunderstandings, or mistakes in patient care. Organizations need to develop methods to detect and address these discrepancies quickly and thoroughly to avoid a negative “trickle-down” effect that could impact a patient (or possibly more) in the future.
Organizational Representation: Every healthcare organization has its own preferences for how it is represented to the public, and this is reflected in the formatting and presentation of its patient care documentation. A quality assessment program, therefore, should ensure that the documentation being generated follows the standards of professionalism and organizational integrity that are expected, especially if that documentation is to be used to illustrate legal and/or regulatory compliance.
If healthcare organizations address all seven of these elements in their quality plan, the seven combine to establish the “Q” factor: A state of being in which physicians, other clinicians, and their support staff have the essential resources needed to tell each patient’s story efficiently and accurately.
Jill Devrick is the AHDI President and a Product Solutions Advisor with 3M Health Information Systems.