The Oops Factor: Are Documentation Edits Nitpicky or Necessary?

February 2nd, 2015 / By Jill Devrick

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.

I don’t want to get into a debate over the usability of the EHR or the ins and outs of speech recognition (at least not in this post). The sins of minor sloppiness are committed by every human being in just about any role. When we speak or write, our brains tend to focus more on sentence structure and phrasing than spelling and punctuation, and often when we edit ourselves we tend to read what we think we wrote rather than what is actually on the screen or page. That’s why a “second set of eyes” on the documentation can be so helpful.

When AHDI and AHIMA created their QA guidelines, they identified the following issues as “Feedback and Educational Opportunities” that would not be counted against the medical transcriptionist when scoring the level of quality of each document, but these errors would be noted, corrected, and reported to the originator in the hope that they would not be repeated:

  • Grammar
  • Plurals
  • Punctuation (gram negative rods vs. gram-negative rods)
  • Capitalization (Ace bandage vs. ACE bandage)
  • Run-on/fragment sentences
    • Abbreviations (organizational rules regarding required expansion or not)
  • Slang and inflammatory remarks
  • Inconsequential typos and omissions (Harrisson vs. Harrison Health Center)
  • Capitalization of drug names (Vancomycin vs. vancomycin)
  • Incorrect word forms (femur vs. femora)
  • Inadvertent repetition (I saw the patient the patient yesterday)
  • Failure to follow organizational stylistic standards (Bilirubin .6 vs. Bilirubin 0.6)

Do these issues matter, or should the “devil’s-in-the-details” people like me learn to let them go? Typos could be interpreted as careless and unprofessional, but at the same time, there is a cost in both resources and efficiency to catch and correct minor details. How much should an organization invest in improving documentation tools, workflows, and support to ensure that the documentation is as clean as possible?

Should our standards for documentation quality vary depending upon who created and/or edited the content? I think the tendency is to give clinicians more leniency when evaluating their documentation quality because their primary role is as a caregiver, and documentation is a time-consuming yet necessary administrative task. However, medical transcriptionists and other healthcare documentation specialists (when they are utilized) are held to a higher standard of quality in their output.

Should our standards for documentation quality depend upon who the audience is for the document? Does the patient, insurance company, legal system, or any other requester of the documentation know who handled the documentation or how each contributor should be held accountable? And should it matter? As a patient and health care consumer, I want the record of my care to be accurate and complete, but I also want it to instill confidence in the organizations and individuals to whom I am entrusting my well-being. If my documentation shows minor errors, should I be concerned about the attention to detail in my care, or should I just trust that my care was excellent at the expense of my documentation?

Further, by not editing, we are not doing the technology any favors. As adoption of natural language processing technologies such as computer-assisted coding become more widespread, and as organizations move towards adoption of reporting and analytical tools to aid in decision support, the quality of the input into these systems is going to become more and more important. Health information is rapidly becoming a strategic asset that organizations can leverage to improve quality, efficiency, and the bottom line. Investing in good documentation systems, standards, and staff is critical to protecting and enhancing the value of an organization’s historical data and documentation.

Learn more about the importance clinical documentation improvement by watching this video.

Jill Devrick, product solutions advisor with 3M Health Information Systems, is Immediate Past President of the Association for Healthcare Documentation Integrity (AHDI).