Importance of Documentation in Healthcare
What is the Importance of Documentation in Healthcare?
Patient care organizations depend on complete and accurate clinical documentation to treat patients. If the data is incorrect, then the patient’s treatment can be improper as well. With the increasing use of automation to generate patient documentation, we must verify the quality of the data created by those processes.
What is medical record documentation?
Patient documentation is the beginning and the end of all patient care. Patients depend on quality documentation because it affects the outcome of the care they receive. Programs that promote continuous clinical documentation improvements are essential to any facility that recognizes the necessity of complete and accurate patient documentation.
Quality Auditing Services from Peachtree Transcription
Peachtree Transcription EHR Integrity Auditing
Documentation quality auditing allows Peachtree Transcription to evaluate the quality of transcriptionist work, establish quality review standards, and create policies & procedures for effectively training Medical Transcription Editors. Speech engine performance is reviewed for efficiency and cost-effectiveness. Additionally, speech recognition quality is monitored, measured, and reported on by verifying content and context for inconsistencies, discrepancies, and inaccuracies.
Furthermore, we ensure that Turn Around Time Performance is controlled and offer you payment reductions if it is not.
MT Quality Assurance Management – Peachtree Transcription quality-control
Peachtree Transcription’s MT Quality Assurance Management Service will verify the quality documentation produced by employees, speech recognition, or third-party companies. As a vendor-neutral service, we can offer the honesty and insight needed to evaluate the quality of patient documentation. Peachtree will pinpoint areas of opportunity to improve the quality of patient care documentation. Our services offer fair and unbiased judgment with the ability to: monitor, measure, and report on the quality of patient care documentation.
Peachtree Transcription EHR Documentation Training
EHR Documentation Training
EHR documentation training will perform an analysis of ehr data, develop customized reports about the data, and provide educational opportunities to users from the data. The EHR documentation trainer is responsible for training clinicians on the use of the electronic health record (EHR), template documentation, and educating physicians with the option of front-end and back-end speech recognition software. Also, we develop, implement, and maintain the clinical narrative, along with templates in the EHR. Peachtree Transcriptions EHR documentation trainers can translate complex workflows into easy-to-use training documentation. We collaborate with the Information Services and Technology (IS&T) staff to manage software and data needs along with technical services.
Primary Responsibilities of Documentation Quality Review Services
* Leads the efforts towards quality documentation, including providing procedures, training, and resources for MTS transcription team members.
* We review, transcribed, and edited reports, through a random selection process. Documentation review is performed concurrently with the audio dictation.
* Evaluates and verifies clinical documentation for spelling, grammar, or punctuation errors that would be deemed critical and non-critical to patient care and compromising to the patient record, organizational, or clinician integrity.
* Verifies patient demographics and information to ensure documentation is for the correct patient and entered into the right encounter.
* Utilization of the AHDI quality scoring criteria along with facility-specific formatting allows for consistently fair documentation reviews.
* Communicates and collaborates with other team members to ensure continuity of care and coordination in services. Additionally communicates unusual circumstances that have possible risk factors or medicolegal issues to the Assistant Director of HIM.
* Our quality auditing maintains monthly statistical documentation for each transcriptionist and the outcomes of the review.
* Performs monthly integrity audits on the MT Analysts to ensure accuracy of the information in the EHR is accurate.
* Monitors the reports in pending status, and makes timely and necessary corrections.