Healthcare Documentation Quality Assessment and Management Best Practices
Whitepaper & Tool Kit
In July 2010 a committee comprised of distinguished experts from the Association for Healthcare Documentation Integrity, the Medical Transcription Industry Association (later called 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.
Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers
Whitepaper & Resource Kit
In July 2014, AHDI and AHIMA released Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers. This document provides a standardized approach to measuring, reporting, and improving documentation for patient safety and documentation accuracy when clinicians are responsible for document creation. The Resource Kit, which is available at no charge, provides the tools needed to create and implement a quality assurance program in healthcare organizations.
The Resource Kit provides a set of explanatory and operational tools that are intended to be adapted by users to their own needs.
What is clinician-created documentation? Medical documentation that is created by a clinician. This type of documentation is created using a combination of front-end speech recognition, drop down menus, or templates in electronic health records.
Although this material is copyrighted, AHDI and AHIMA give blanket permission to any potential users of the Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers document to download and employ the contents of the Resource Kit. We do ask that, where appropriate, AHDI and AHIMA be credited with the creation of those contents.
"The AHDI QA Best Practices for Clinician Created Documentation toolkit has been a wonderful tool! It has helped us to set up a QA program for this, along with guidelines as to what are critical errors and noncritical errors. Our program changes weekly, but we are finding better ways to do things. Some of the changes aren't very big but, as it evolves, it is only getting better. Hopefully we will have a solid program in place within 6 months!" -- Ardyce Heffernan, CHDS
AHDI's Statement on Quality Assurance for Medical Transcription