Documentation Quality: Time to Line up the Ducks

May 20th, 2015 / By Jill Devrick

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.

The article doesn’t state that any particular documentation method is bad, but it does point out the many ways that assumption and lack of planning can cause undesirable results. What it comes down to is a need for balance on many levels. First of all, organizations need to balance their goals around achieving meaningful use, implementing technology, preparing for ICD-10, and other initiatives, against the ultimate goal of protecting and restoring patients. EHRs, speech recognition, and other technologies have the potential to achieve greater efficiencies, cost savings, and productivity for healthcare organizations. However, these achievements don’t mean much if we do not consider all of the ways risk can be introduced and take steps to address misconceptions, assumptions, habits, biases, busyness, apathy, fatigue, defiance, individuality, and all of the other humanness that we insert into our work life.

One of the most important factors to remember when working towards this balance is that technology is intended to enhance the human experience, not inhibit it. Humans created technology, and humans need to take the time to ensure that system configuration is well designed, workflows are adapted to be practical and intuitive, training is comprehensive, support is ongoing, and all of these efforts factored together yield continuous improvement. If any of these aspects of technology implementation are treated with lesser value, then balance cannot be achieved. I don’t believe there will ever be a technology implemented that is perfect on the first try. As in the rest of life, technology, and how it is designed and implemented, is a work in progress, and we need to always treat it as such.

The Joint Commission article goes into detail about the various documentation practices that introduce risk to patients, as well as recommendations for developing continuous quality improvement programs so that issues can be addressed and prevented from recurring in the future. I am happy to see that TJC references the QA best practices developed by AHDI and AHIMA a few years ago (discussed in many of my previous blog posts if you would like to learn more). I believe that the HIM and medical transcription professions have a lot to contribute to the discussion and resolution of documentation quality issues for the healthcare industry, and I am hopeful that they will be working with TJC soon to develop standards for documentation that will help healthcare organizations build risk management and quality improvement into their configurations, workflows, training programs, and more. It’s clear that TJC wants us to get our documentation quality ducks in a row as soon as possible.

Speaking of medical transcriptionists (and other healthcare documentation specialists), I would like to wish everyone a happy National Medical Transcription Week (NMTW) from May 17-23. After 20 years working with MTs across the country, I continue to be inspired by the resilience and dedication of this special group of professionals who truly want to protect patients and the providers that they support through complete and accurate documentation. I’ve never seen a group of individuals more passionate about “getting it right,” and know they will be a significant force in addressing documentation quality across the healthcare system through traditional transcription, speech recognition editing, template development, provider training and support, EHR documentation review, and much, much more.

The theme of NMTW this year is “Patient Care Documentation Brought to Life.” I like the use of “truth and vitality” in describing how MTs support patients and providers in telling the patient’s health story. I also like the idea of a “culture of respect” mentioned by Laura Bryan in TJC’s article. I think truth, vitality, and respect are exactly what we need to build a culture that embraces technology for how it can improve documentation workflows while also protecting the interests of patients and everyone on the healthcare team.

Jill Devrick, product solutions advisor with 3M Health Information Systems, is Immediate Past President of the Association for Healthcare Documentation Integrity (AHDI). Want to learn more about clinical documentation improvement? View our infographic.