Documentation Quality in a Perfect World

With all of the challenges around healthcare documentation lately, it’s fun to dream of “documentation utopia.” In other words, what are the guiding principles of documentation quality that ensure every patient encounter is documented efficiently and accurately, with the appropriate detail and timeliness? The following ideas inspired the development of the existing AHDI/AHIMA best practice recommendations.

Every document is an accurate, detailed, and complete description of the patient encounter. A high-quality document will not leave blanks or inconsistencies that require queries or addenda. Physicians and other caregivers need good tools to capture the information efficiently without bogging down their workflow, cutting corners, or making errors. As the ICD-10 date looms closer, healthcare organizations should ensure that each department has the optimal content capture technology for their situation, whether with dictation/transcription, speech recognition, direct template entry, or other methods.

ALL healthcare documentation is eligible for quality assessment (QA), regardless of content capture method. Most transcription organizations have some sort of quality control workflow, at least for concurrent review, to address any blanks before sending back to the dictator. However, in transcription the assumption is that the physician will review the content, address any “flags,” and finalize the document content before signature. As the percentage of clinician-generated documents continues to rise, the “second set of eyes” provided by transcription is being removed from the workflow. Thus, healthcare organizations need to determine how clinician-generated documentation is monitored (before CDI review) and how quality issues will be addressed. Personally, I think this is a great way to repurpose experienced medical transcriptionists as dictation/transcription volumes decrease. Resource constraints may not allow all content to be reviewed, so it is important to determine QA priorities and enforce them consistently.

Quality assessment workflow needs to be consistent, unbiased, and provide feedback for continuous improvement. The QA process needs to be governed by objective standards that define error categories, their severity, and the actions necessary when errors are found and addressed. In other words, every document, narrative section, or data field should be assessed in the same way, regardless of the author or the reviewer. Organizations need to define and prioritize what matters to them regarding content quality. For example, the AHDI/AHIMA recommendations specify that a critical error could impact patient care and has a higher point value than a minor error that does not affect understanding. The QA process should always include a feedback loop and constructive dialogue with the author so that similar errors can be avoided.

Documents are available to whoever needs them, whenever and wherever they are required. A high-quality document isn’t very helpful if it isn’t available to the people who need it. Patient care can be impacted by delays in documentation, as can coding, billing, and reimbursement. Turnaround time should be considered when assessing documentation quality, as should the document distribution process to ensure workflow and systems are as efficient as possible.

How close can healthcare organizations get to these principles of “documentation utopia?” Many factors, such as financial, technology, and human resource constraints, come into play in determining the degree to which an organization can commit to documentation quality assessment, but these principles are worth considering to ensure that the documentation generated for each encounter reflects the professionalism and quality of care being provided. In my next post, I will discuss the characteristics of a comprehensive QA program.

Jill Devrick is the AHDI President-Elect and a Product Solutions Advisor with 3M Health Information Systems.

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