Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Introducing the Tool Kit
In July 2010 a committee comprised of distinguished experts from the Association for Healthcare Documentation Integrity, the Medical Transcription Industry Association (now the Clinical Documentation Industry Association), and the American Health Information Management Association published a comprehensive revision of standards and best practices in healthcare documentation quality assessment and management. This document, Healthcare Documentation Quality Assessment and Management Best Practices, provides a standardized approach to measuring, reporting, and improving documentation for patient safety and documentation accuracy. Moreover, fundamental principles of quality in healthcare documentation are reevaluated and revised in light of the new technological and policy environments of the 21st century.
The Quality Assessment and Management Tool Kit has been created by another group of industry experts to assist all users to understand and implement this new approach. It provides a set of explanatory and operational tools that are intended to be adapted by users to their own needs. Although this material is copyrighted, AHDI and CDIA give blanket permission to any potential users of the Healthcare Documentation Quality Assessment and Management Best Practices document to download and employ the contents of the Tool Kit. We do ask that, where appropriate, AHDI and CDIA be credited with the creation of those contents.
Quality Assessment and Management Tool Kit Contents:
“Why the Changes?” handout – A one-page summary explaining the motivation and purposes behind the development of the new quality assessment and management principles and procedures. This brief document is suitable for presentation to any stakeholders in the health documentation process, including administrators, healthcare providers, and others.
Adoption Guide – A detailed narrative based on the continuous quality improvement Plan, Do, Check and Act (PDCA) cycle, with suggestions for operationalizing the 2010 document.
“QA Best Practices” Power Point presentation – A basic summary of the contents and organization of the Healthcare Documentation Quality Assessment and Management Best Practices document; slides will provide the bases for more extensive discussion where appropriate.
Checklists – These flexible tools are linked to specific operations in the Adoption Guide, and can be customized by users to meet their own needs.
Scoring Spreadsheet – Another adaptable tool that can provide the basis for creating a user-specific set of quality assessment records.