Twenty years ago, I began my journey in healthcare documentation technology. I’ve been traveling up and down memory lane for the past few days, thinking about how the healthcare industry has changed, and healthcare documentation tools and processes along with it.
Back in the mid-90s, healthcare documentation was almost entirely created for paper, whether it be handwritten notes and forms or transcribed documentation. Many of the hospital medical transcription departments I visited at that time were transitioning from typewriters and fancier word processing units to networked workstations running our DOS-based ChartScript application. I remember transcriptionists being concerned because a computer-based transcription system could measure productivity more consistently and precisely than the manual methods employed with typewriters and word processors. Continue reading
The Joint Commission’s (TJC) current “Quick Safety” article, intended to advise healthcare organizations about safety and quality issues, is about the potential risks when technology and human workflow practices do not ensure patient documentation is accurate, complete, and understandable. Although the title of the article is, “Transcription translates to patient risk,” the gist of the article is that documentation being captured via dictation and transcription, speech recognition technology, direct entry into templates, straight typing by providers, or any other method, needs to be reviewed with utmost care to protect patients from injury and death. Continue reading
For the past two years, I have been fortunate to attend the HIMSS Annual Conference & Exhibition in both New Orleans and Orlando. HIMSS puts on a massive event for about 38,000 people, so it’s definitely a great place to learn and network around the newest technologies, trends, and solutions in healthcare information technology. HIMSS15 kicks off in Chicago on April 12, and although I am unable to attend this year, I’ve been thinking about the conversations and ideas I hope will be generated by the organizers, presenters and attendees. Continue reading
Last month, AHDI created a new Facebook group called “SR Errors – Funny or Fatal?” as a forum for healthcare documentation specialists (HDS) to share speech recognition “bloopers” that they caught during the editing process.
The submissions vary from hilarious:
“The patient slipped on the ice and fell on her Botox.”
Dictated: “Lipitor 20, two pills a day”
Speech recognition result: “Lipitor 22 pills a day” Continue reading
In my last two “Oops Factor” posts, I discussed the necessity of addressing critical errors in healthcare documentation that could affect patient safety, as well as non-critical errors which may not harm the patient, but could impede the reader’s understanding of the content. But what about the nitpicky stuff? How far should editing go in the electronic world in which we now work?
I remember when I started consulting with hospital transcription departments almost 20 years ago that it mattered very much how the document appeared on paper and that every detail of spelling, grammar, punctuation, and other stylistic rules were maintained. Nowadays, adoption of speech recognition and direct EHR entry have fostered a new mindset of getting the documentation created as quickly as possible without worrying about minor issues. The advent of this mindset is in direct correlation to the expectation that the new technologies are efficient enough that physicians and other clinicians should create their own documentation without assistance. Continue reading
Back in September, I wrote a blog about documentation errors and listed various types of critical errors that could potentially impact patient safety, care, or treatment. Clearly, errors that can cause harm are the first and most important to detect and resolve. Some errors don’t carry such severe potential consequences, but they still impact documentation quality.
Why should we be concerned about noncritical errors if their presence does not hurt the patient? First, these errors can affect perception about the author and/or organization if they are not addressed and corrected, especially if frequent or habitual. No physician or administrator wants to be questioned in court concerning incomplete, inaccurate, or just plain sloppy documentation because it introduces doubt regarding the attention to detail and professionalism of the organization and individuals providing care to the patient. Continue reading
Last week I checked in on Facebook from the AHIMA convention in San Diego. My brother, who attends San Diego Comic-Con religiously every year, decided to weigh in:
Brother: My San Diego convention is superior to your San Diego convention.
Me: My convention is more conventional than your convention.
Brother: I expect you’ll have better Cosplay, though.
Me: Lots of Clark Kent and Lois Lane types.
It turns out this exchange fit perfectly with the vibe at #AHIMACon14 over the following three days. I arrived at the Monday general session in time to see and hear several inspirational messages about how innovation and, as AHIMA CEO Lynne Thomas Gordon put it, “embracing reinvention,” are the keys to success in health information management. Continue reading
When reviewing and evaluating healthcare documentation from a quality and integrity perspective, a QA reviewer is looking to capture and address any error, regardless of source and severity. However, some errors are more critical in nature because of their potential impact upon patient safety, care, or treatment. Other errors may have an impact upon documentation quality, but their presence does not change the meaning of a document or affect patient care. In this post I would like to discuss critical errors discovered through documentation QA, but stay tuned for future posts addressing noncritical errors and educational feedback opportunities. Continue reading
Last week I attended my first CDI Summit. As a specialist in the document creation process, I knew that I was going into the conference with a different perspective on healthcare documentation than most attendees, but I was hoping to see how the goals and processes of clinical documentation improvement (CDI) align with the goals and processes of documentation capture and quality assurance.
I was happy that all of the sessions I attended related in some way to how the documentation is being captured in health care, either through traditional dictation and transcription, speech recognition, templates, or direct data entry. On several occasions I heard the CDI mantra, “If it isn’t documented, it didn’t happen,” because the focus of CDI is on attaining accurate and timely documentation that reflects the scope of services provided to the patient. Continue reading
Last week I attended the Association for Healthcare Documentation Integrity (AHDI) conference in Las Vegas, Nevada. This time around I was honored to serve as president, which meant I had the privilege of introducing keynote speaker Ronald Wyatt, MD, the Medical Director within the Division of Healthcare Improvement at The Joint Commission. He kicked off the conference by encouraging the medical transcriptionists and other healthcare documentation specialists to continue supporting clinicians in capturing and editing documentation so that quality is improved and errors are eliminated. He advocated for patient care documentation that is highly accurate, complete and reliable, and asked attendees to do all that they could to build an environment in which a zero error rate (and zero patient harm) is the expectation. Continue reading