Patient Care Documentation Brought to Life
Download the 2015 poster
Guardians of Health Record Integrity
Prevent Errors. Preserve Stories. Protect Lives.
Healthcare documentation specialists play a critical role in capturing and preserving America's health story. As guardians of data integrity, they are the clinician's partner to ensure an accurate, secure, and meaningful health record for patient care and safety. Healthcare documentation specialists chronicle the information-rich narrative that is the cornerstone in clinical decision-making and coordination of patient care.
By harnessing this workforce's expertise in data integrity and medical language, clinician time, coding, and revenue are optimized and the data governance strategy is reinforced and strengthened. Healthcare documentation specialists provide front-line document risk management, monitoring documents for:
- wrong patient/wrong content (demographic mismatches);
- wrong provider name;
- wrong dates of service;
- incorrect work types;
- medication dosage errors;
- right/left, male/female inconsistencies;
- medical contradictions; and
- other missing elements and speech recognition errors.
The 2009 error study report Improving the Accuracy of Narrative Patient Notes: The Role of Documentation Specialists in Supporting Physician Use of EMRs results showed the error rate at 22% for dictation and a 52% error rate for dictation with speech recognition translation before transcription and editing was performed. In stark contrast, the study showed final reports produced by healthcare documentation specialists consistently achieved accuracy rates higher than 99%.
There is no doubt that critical errors negatively impact patient care and safety. Help clearly demonstrate that healthcare documentation specialists are helping to save lives by:
- Advocating how healthcare documentation specialists are well-positioned to identify important quality issues around changes in the process of healthcare documentation that can enhance an organization’s fiscal outcomes.
- Demonstrating the importance of how a credentialed workforce protects patient record outcomes by ensuring that only skilled, qualified, and accountable individuals have access to patient records for the purpose of creating, modifying, and formatting the clinical care record.
- Partnering with clinicians to help them adopt and implement policies and training practices found in our Dictation Best Practices Tool Kit to promote high-quality dictation and ensure the best documentation outcomes.
- Serving as a knowledgeable resource for the public in helping to educate them about obtaining and checking their medical record for accuracy through the promotion of the Your Record Speaks campaign.