Healthcare Documentation: Drawing a Blank

January 3rd, 2014 / By Jill Devrick

No, I don’t have writer’s block. I just have blanks on my mind.

Healthcare documentation specialists (HDS) such as medical transcriptionists, speech recognition editors, or quality analysts insert a “blank” or “flag” into a document to indicate to a physician where information is missing, incorrect, or questionable. But are blanks good or bad? In a perfect world, the physician would dictate or directly enter the document clearly, accurately, and with all relevant details the first time around. However, life is messy, and clinicians are very busy human beings, so there are many reasons why resolution of blanks is a necessary part of the document creation process. The HDS’s eyes and ears are important to ensure the quality of the documentation. First and foremost, they look and listen for potential patient care and safety concerns, but they also ensure the patient’s story reflects the professionalism and integrity of the individuals and organizations involved in the patient’s care.

When an HDS listens to or reads a document, he/she is using personal knowledge and astute research skills to produce as accurate and complete a document as possible. Usually, a search through a reference book or web site, or a search for previous documentation on the same patient or by the same dictator will yield the answer needed to fill a blank. However, the HDS sometimes has to identify points of uncertainty so they can be rectified by the responsible physician. As my colleague Janice Jones advises, “When in doubt, leave it out. Do not guess. Flag the document and ask the physician or clinician to clarify.” So, blanks within a document may be seen as negative when they are returned to a physician, but they are positive evidence of due diligence on the part of the HDS team to support the physician in generating high-integrity documentation.

A well-educated and experienced HDS will usually be able to address issues within a document without assistance. However, on occasion the HDS may refer a dictation to a colleague or QA reviewer for a second (or third or fourth) opinion before returning the resulting document to the physician for clarification. Ultimately, the HDS team wants to use its knowledge, research savvy, and collaboration skills to resolve as many missing, unclear, or questionable content issues as possible without having to refer to QA review or the physician.

Blanks are most commonly sent back to the dictator for these reasons:

  • Audio file distortion (tunnel echo, muffled, or other effect that affects clarity)
  • Clipped, cut off, incomplete, or omitted dictation (caused by distractions or mic movement)
  • Suboptimal dictation practices (talking very quickly or other bad habits such as eating, driving, or any attempt at multitasking)
  • Discrepancy in dictated details (early information doesn’t jive with later sections)
  • Author-requested blanks (physician will add information when available before signature)
  • Inability to verify terminology (new drug, equipment, or procedure not widely documented)
  • Unknown person or place (can’t find the patient, visit, order record, or can’t verify location)
  • Preexisting blank that has been copied forward (physician reuses a section from a previous document but doesn’t realize it contains unresolved blanks)

I share this information because I have realized lately that many people, even in the healthcare industry, do not have a good understanding of what an HDS does. My impression is that many people believe medical transcriptionists and others involved in document creation only listen to the dictation and translate that to text, as if it was a production-based data entry role. This could not be further from the truth. HDS have been querying physicians about documentation issues for many years, but instead of calling them queries, as is the term used by clinical documentation improvement (CDI), they have called them blanks or flags.

Because their goals are so similar, or at least move in the same direction, I think many opportunities exist for the HDS team that supports document creation efforts to work with the CDI team that facilitates documentation quality. I think it’s a conversation that could bring a lot of value to healthcare organizations by combining efforts and expertise towards documentation excellence.

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