Quality Assurance Practices

Peachtree Transcription’s Quality Assurance Practices

Medical records are a vital component to the care of patients, and the processes responsible for generating that information is quality monitored. Timely and consistent feedback to those involved with the creation of the electronic health record improves outcomes for patients. Attention to quality should reflect an understanding that even minor errors in the EHR can diminish the credibility and perceived competence of the healthcare provider. Looking forward, AI’s ability to make complex decisions is dependent upon the complete and correct entry of patient data into the EHR.

Rationale

Malpractice lawsuits in the United States are on the rise, and those involved in those processes understand the importance of excellent documentation of patient care. The most fundamental reason for promoting quality documentation is to enhance the ability of the physician to make informed decisions with an accurate and complete history of the patient. Any error in the healthcare record is a potential risk for the patient and the healthcare provider. 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 is evidence of care for any healthcare facility. Documentation begins at the point of contact, and it is critically important to notate the encounter with accuracy and precision. A partnership between the patient, the healthcare provider and the documentation team is required To achieve accurate and complete healthcare documentation.

Establishing a robust quality assurance process ensures that medical transcription practices are consistent and precise. Whether an MT is a transcriptionist for the document or an editor, human judgment will always be involved in this process. The degree of accuracy that is achievable depends upon the individual’s experience and skill, in addition to the acoustical quality of the dictation (including 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

Our quality assurance program is successful because of the following principles:

Meaningful implementation of a quality assurance review program requires the comparison of transcribed reports with the actual voice recording of the dictation. Reading transcribed patient reports without the audible copy does not provide an accurate comparison of the review.
The review applies industry-specific standards as provided by current resources and references. When evaluating style, punctuation or grammar, the AAMT Book of Style is the industry standard.
The review encompasses attention to risk management issues and the documentation standards of accreditation and healthcare compliance agencies.
Accuracy scores utilize a numeric calculation that compares errors against the length of the report. A minimum quality threshold of 98% is used to establish a benchmark.
Timely and consistent feedback to the medical transcriptionist eliminates the repetition of errors.
All measurements, standards, and benchmarks are disclosed to the medical transcriptionist and included written guidelines for the same.

Application of Principles

Organizational policy should set the application of these principles and the development of a documentation quality assurance program that incorporates them. Peachtree Transcription recommends the following considerations in doing so.

Frequency:

All reports transcribed by new medical transcriptionists undergo full quality review indefinitely. Once quality is proven, 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 review period.

Delineation:

Peachtree Transcription’s quality review manual defines the qualification of an error, and the number of points reduced by it. A “critical error” is one that can compromise continuity of care, such as medical word misuse and omitted dictation. A “major error” is one that compromises the integrity of the document without risk to patient care, such as misspellings, demographics errors, and formatting errors. A minor error is one that compromises neither patient care or the integrity of the report. However, it stills represents an area of recommended improvement to the transcriptionist, such as capitalization, punctuation and other minor style and grammar errors.

Accuracy:

The goal of 100% accuracy for every document sent to the healthcare provider is one that everyone should desire. While perfection is not impossible, Peachtree Transcription recommends a 98% or higher benchmark for documentation quality review. It is important to note that this should be the goal of transitioning a transcriptionist through any comprehensive quality assurance program. The quality assurance program should not be used to penalize a new transcriptionist but instead used as the benchmark to compare all documentation too.

Purpose:

Performance improvement through ongoing feedback and education is the primary goal of our Quality Assurance program. The program facilitates the correction of errors and is a way to build confidence in individuals with limited experienced judgment, the ability to discern client/chart-ready documents from those that are needful of the quality review process. Attention to quality must also include a commitment to the ongoing professional development and continuing education of the medical transcriptionist as a means of ensuring overall continuous quality improvement.