Defining Documentation Quality

July 17th, 2013 / By Jill Devrick

I’ve been reading a lot of blog posts and articles lately about the many challenges the healthcare industry faces around healthcare documentation. Technology, new regulations, and other factors continue to change how documentation is created and processed, but are those changes for the better? How can we know that the documentation being created is of an acceptable level of quality, who defines what that level of quality is, and who is accountable for documentation quality?

For many years, medical transcriptionists have been subject to quality standards defined by their employers without an industry-wide standard to use as a guide. Today, documentation is generated by many contributors using a variety of methods. In response to changes in document creation workflow, the Association for Healthcare Documentation Integrity (AHDI) partnered with AHIMA in 2010 to develop the “Healthcare Documentation Quality Assessment and Management Best Practices,” which address quality issues in documentation regardless of the format (paper or electronic) or method of entry (transcription, speech recognition, direct EHR entry, etc.). This document and its associated toolkit was created to provide both healthcare providers and medical transcription organizations with a more standardized approach to measuring, reporting, and improving the quality of healthcare documentation in order to achieve consistent patient safety outcomes, accurate coding and billing practices, and improved protection against fraud and malpractice.

Because documentation quality is such an important topic, I am going to share a series of posts with my thoughts on the basics of the quality assessment best practices, as well as the rationale AHDI and AHIMA used in creating them. I hope that the healthcare industry will use these guidelines as a starting point in the dialogue about how documentation quality is defined, who is accountable for it, and how it can be improved.

So, what is the point of having a quality assessment program for healthcare documentation? AHDI and AHIMA identified six key goals. Documentation should be assessed to ensure that it is:

  • Clear: The document makes sense, and communicates what the author intended to communicate about the patient and his/her care, with little or no ambiguity.
  • Consistent:  The content of the document matches up and does not conflict with other information documented in the patient’s record for the encounter.
  • Accurate:  The information in the document is true and correct.
  • Complete:  All of the required detail is present to provide a comprehensive story of the patient’s care.
  • Timely:  The document is created, finalized, and available for reference within an acceptable turnaround time.
  • Compliant:  The content and organization of the document meets the standards and best practices outlined by the healthcare organization and the applicable regulatory organizations that monitor it.

In my next several posts, I’ll discuss the practical implementation (and inherent challenges) of these goals.

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