This week is National Medical Transcription Week, and I would like to thank all of the hardworking medical transcriptionists and other healthcare documentation specialists (HDS) who support physicians every day in creating complete, accurate, and high quality patient care documentation. This year’s theme is “Guardians of Health Record Integrity;” so I would like to highlight a very important but often overlooked part of the healthcare documentation process, quality assessment (QA).
Within the healthcare documentation process, there are three different workflows for QA:
Flagged concurrent review As healthcare documentation specialists (HDS) complete each job, they may encounter blanks, inconsistencies, or other questionable content that they are unable to resolve even after extensive research. Because guessing is never acceptable in healthcare documentation, the HDS flags the document so that it will be routed to a QA reviewer for further scrutiny. The QA reviewer will attempt to resolve the flagged issues and then send the document on to the dictator for authentication. Flagged concurrent review ensures that the healthcare documentation team has done its due diligence in creating a complete and accurate document within the context of the patient’s situation before it is returned to the dictator. However, sometimes issues in the dictation have to be resolved by the dictator before signature.
Sampled concurrent review When an HDS is new or inexperienced with an account, specialty, dictator, or work type, her employer will likely send a certain percentage or number of her documents to QA for review (and feedback, if necessary) before they are authenticated and distributed. In many cases, the employer will review 100% of the documents in a specific category for a new HDS until they are confident that the HDS has the knowledge and skills to process those jobs without assistance. Often the sampling rate will be reduced incrementally as quality goals are met to coincide with departmental guidelines. Some organizations also use sampled concurrent review to monitor individuals who are on a performance review plan and need more oversight. This form of QA enables clear, consistent, real-time feedback intended to increase the knowledge and improve the accuracy of the HDS.
Retrospective review A seasoned HDS has typically earned the employer’s trust and does not require sampled concurrent reviews, but sometimes a random sample of previously completed work is reviewed in order to ensure that the expected level of quality is being maintained. Retrospective review occurs outside of the real-time document creation workflow, so it does not affect established turnaround times like concurrent review can. However, because the documents being reviewed have already been authenticated by the dictator and distributed, it is important to conduct retrospective reviews before audio files are purged so that the content of the document can be compared to the original dictation. Some organizations use retrospective review as part of an HDS’s annual performance review. Others use retrospective sampling to look at quality for specific account, specialty, dictator, or work type and determine if improvements could be made to tools and processes that would prevent recurring problems.
All three forms of QA workflow are essential to ensuring that each patient’s narrative is as clear, consistent, accurate, complete, timely, and compliant as possible. This week, be sure to show your appreciation to the medical transcriptionists, QA reviewers, and other healthcare documentation specialists in your organization who are so passionate about the details of every patient’s story. Their behind-the-scenes efforts protect patients, physicians, and the healthcare organizations that they serve every day.
Jill Devrick is the AHDI President and a Product Solutions Advisor with 3M Health Information Systems.