Quality Assessment in Healthcare Documentaiton - Best Practices
-July 2010
- Association for Healthcare Documentation Integrity (ahdi)
- Medical Transcription Industry Association (MTIA)
- American Health Information Management Association® (AHiMA)
Executive Summary
Technological advances combined with a national agenda for healthcare reform are shifting health information processes and practices from paper-based records to the electronic health record as the dominant medium by 2014. As this transformation takes place, the quality of patient records becomes a critical focus for patient safety and improved patient outcomes. Quality practices of both service providers as well as inhouse medical transcription departments benefit from a more standardized approach to measuring, reporting, and improving the quality of healthcare documentation in order to achieve consistent patient safety outcomes.
Due to the heightened pace of transition to electronic health records, the boards of directors of the American Health Information Management Association (AHIMA), the Association for Healthcare Documentation Integrity (AHDI), and the Medical Transcription Industry Association (MTIA) felt it was urgent to reassess the process of quality measurement in healthcare documentation. All three boards agreed to initiate a call to action to deliver on an updated best practices document for quality assessment in healthcare documentation. In April 2009, the directors called upon a workgroup of nationally recognized experts in health information, medical transcription, health information technology, and academia to convene a Quality Summit to develop best practices in quality assessment for healthcare documentation that would impact quality processes for the foreseeable future.
To achieve this task, the group first established the fundamental principles of quality. The workgroup then focused on factors that affect quality as well as strategies to minimize these factors. An in-depth analysis of blanks was also performed, as blanks are a critical factor in providing accurate patient reports. This Best Practices document applies the Plan, Do, Check, Act (PDCA) method of continuous quality improvement. The PDCA approach to planning, decision-making, and problem solving is described in detail in Appendix C. The results of this committee’s work is described herein and provides a blueprint for the application of a leading-edge quality program that is compatible with paper-based medical records, hybrid EHR record systems, as well as fully implemented electronic health record systems.
Due to the heightened pace of transition to electronic health records, the boards of directors of the American Health Information Management Association (AHIMA), the Association for Healthcare Documentation Integrity (AHDI), and the Medical Transcription Industry Association (MTIA) felt it was urgent to reassess the process of quality measurement in healthcare documentation. All three boards agreed to initiate a call to action to deliver on an updated best practices document for quality assessment in healthcare documentation. In April 2009, the directors called upon a workgroup of nationally recognized experts in health information, medical transcription, health information technology, and academia to convene a Quality Summit to develop best practices in quality assessment for healthcare documentation that would impact quality processes for the foreseeable future.
To achieve this task, the group first established the fundamental principles of quality. The workgroup then focused on factors that affect quality as well as strategies to minimize these factors. An in-depth analysis of blanks was also performed, as blanks are a critical factor in providing accurate patient reports. This Best Practices document applies the Plan, Do, Check, Act (PDCA) method of continuous quality improvement. The PDCA approach to planning, decision-making, and problem solving is described in detail in Appendix C. The results of this committee’s work is described herein and provides a blueprint for the application of a leading-edge quality program that is compatible with paper-based medical records, hybrid EHR record systems, as well as fully implemented electronic health record systems.
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