Clinician Created Documentation Quality Auditing

Peachtree Transcription Associates partners with its clients to provide an unbiased complete review of the integrity of the patient documentation record.  What separates Peachtree Transcription’s Quality Auditing program from other services is the fact that we listen to the dictation while reviewing the transcription. Hearing what the physician actually dictated ensures that the the quality reviewer will not have to make assumptions about the patient encounter. In addition, physicians receive immediate notification when abnormalities are discovered.  Healthcare is a partnership, and we are the partner that you can count on.

Common Documentation Mistakes:

1. Copy and pasting wrong patient information or wrong visit information
2. Physician signed off before reviewing the documentation
3. Unmitigated template creation and modification
4. Poor EHR Design
5. Incorrect or inappropriate abbreviations
6. Wrong template
7. Duplicate patient, incorrect visit
8. Wrong box checked
9. Inconsistent Speech engines

Documentation Improvement Suggestions:

1. Speech engine performance should be constantly evaluated and reviewed
2. Assign an individual that will be responsible for reviewing and uploading templates
3. Ensure templates contain required statements for billing reimbursements and abide by applicable state laws
4. Use of templates with multiple change requests should be avoided
5. Never let the transcriptionist assume which template to use
6. Dictators with poor speech engine performance are more cost-efficient with straight transcription
7. Continuously update documentation policies and procedures when necessary