Patient Documentation Quality

Rationale

With the number of malpractice lawsuits in the United States increasing yearly, those involved in the documentation of patient care must consider the correlation of that documentation to compromised care and malpractice litigation. While the most fundamental reason for supporting and promoting quality documentation is to ensure continuity of patient care, it is essential to recognize that attention to quality must address the issue of how all errors in the healthcare record have the potential to put at risk either the patient, the healthcare provider or both. Research indicates that errors in the patient record, whether major or minor, medical or grammatical, are potentially useful to plaintiff attorneys and the case they attempt to bring against both the healthcare facility and its providers.

The patient record about the encounter is the only real evidence of care in any healthcare facility.  Therefore, it is a necessity to record all aspects of that contact accurately.  Completeness in healthcare documentation involves a partnership between the patient, the healthcare provider, and the documentation team.

A reliable quality assurance process ensures that medical transcription practices are consistent and accurate. Whether an MT is the transcriptionist of the document or is an editor of the same, human judgment will always be involved in this process. The degree of possible accuracy depends upon the experience and skill of the MT coupled with the acoustical quality of the dictation and the: organization, focus, and language proficiency of the author.

A skilled medical transcriptionist will have a broad knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values, in addition to proficiency in English usage, grammar, punctuation, and style. The medical transcriptionist will also possess refined intuitive skills and sound judgment.

Principles of Patient Documentation Quality

Reviewing electronic health records for quality requires consistent error scoring with regular reviews.  

We find the best method for quality review is comparing the transcribed report with the clinician’s audio dictation.  Reading the electronic health record while listening to the audio is the only way the clinician’s findings are accurately reported.  The review should apply industry-specific standards as provided by current resources and references along with facility-specific criteria. When evaluating style, punctuation, or grammar, the AAMT Book of Style is the industry standard.
The review should encompass attention to risk management issues and the documentation standards of accreditation and healthcare compliance agencies.
Accuracy scores (ratings) are a numeric calculation that assigns points to error types. Peachtree Transcription recommends that 98% accuracy is the minimum quality threshold upon which to establish a benchmark.
The review provides timely and consistent feedback to the medical transcriptionist to eliminate repetition of errors.
All measurements, standards, and benchmarks are disclosed to the medical transcriptionist and include written guidelines for the same.

Application of Principles

The application of these principles will sustain a successful quality assurance program. Peachtree Transcription recommends the following considerations in doing so:

Frequency: All reports transcribed by new medical transcriptionists undergo a full review until you are satisfied with their competency and judgment. At that time, blind review by periodic sampling of transcribed reports should be performed to ensure ongoing compliance with quality standards. Peachtree Transcription recommends selecting a 3-5% sampling of documents for the period reviewed.

Delineation: Clear qualification and quantification of errors should are established for document evaluation. A critical error can compromise the continuity of care, such as medical word misuse and omitted dictation. A major error can compromise the integrity of the document without risk to patient care, such as misspellings, demographics errors, and formatting errors. A minor error compromises neither patient care nor reports integrity but represents an area of recommended improvement to the transcriptionist, such as capitalization, punctuation, and other minor style and grammar errors.
Accuracy: While the efficiency of 100% should be the standard to which every document aspires, Peachtree Transcription recommends that a benchmark established is no less than 98%. It is important to note that the goal of scoring the transcriptionist is a tool to make them better at their profession.  A comprehensive quality assurance program is not used to penalize a new transcriptionist but is established as the standard for transcription.  Additionally, despite every attempt to develop an objective evaluative tool for QA, the review is inherently subjective and flexibility is required.

Purpose: Ongoing feedback, education, and performance improvement is the goal of any quality assurance program. The scope of the program is not limited to the correction of errors but focuses on establishing confidence in individuals.   Attention to quality also includes a commitment to the ongoing professional development and continuing education of the medical transcriptionist as a means of ensuring overall continuous quality improvement.