PDCA Quality Principles for Clinical Documentation

PDCAAs the healthcare system in the U.S is shifting from paper-based to electronic health records (EHRs), it has become very important to focus on the quality of patients’ records for improved and consistent patient safety outcomes. This has made the American Health Information Management Association (AHIMA), the Association for Healthcare Documentation Integrity (AHDI), and the Medical Transcription Industry Association (MTIA) reassess the process of quality measurement in clinical documentation and develop the Plan, Do, Check, Act (PDCA) method of continuous quality improvement. Quality principles are set out in the first phase (Plan) of this method, to ensure the quality of healthcare documentation.

The principles of quality are comprehensive codes of conduct which ensure the accuracy, accessibility and overall value of patients’ medical records so as to understand the symptoms, treatments and progress of the patient. The following principles apply to the quality of the documentation.

  • Verifiability – Customers having quality standards as per the contractual agreement must be able to verify the quality checks performed. The quality check results must be understood clearly without any area of ambiguity. The key to verifiability is well-defined error definitions.
  • Definability – Error definitions are important to understand the nature of an error and generate quality medical records that meet industry standards.
  • Measurability – A quality-assessment program for healthcare documentation allows the complete understanding of the methodology and formulas used in the assessment. It is transparent so that all parties can verify it and arrive at a clear and concise quality rating that is statistically valid.
  • Consistency – It is required to standardize variables (define errors and their point values) and then implement a standardized method for error determination in order to achieve consistency in quality.
  • Integrity – A good partnership between the author and transcriptionist is needed to achieve integrity in healthcare documentation. The author must provide clear, unambiguous, and complete dictation while medical transcriptionists should retain the author’s style and intended meaning while including accurate demographics and appropriate distribution notations into the transcribed or edited reports. With continuing education and commitment, medical transcriptionists add integrity to the process.

Digital health records prove to be an efficient tool for physicians to generate complete and concise medical documents. They are supposed to reduce transcription errors and support better patient outcomes. A study by the Agency for Healthcare Research and Quality revealed that this digital record system enhances nursing care, coordination and patient safety as well. However, digital health records will become really beneficial for healthcare professionals only if they leverage their EHR to improve its quality through ‘meaningful use’.

To meet the meaningful use criteria, hospitals must implement certified EHR technology and use that technology to achieve specific objectives. The meaningful use criteria, objectives and measures evolve in three stages – Stage 1 (2011-2012) includes data capture and sharing, Stage 2 (2014) includes advanced clinical processes and Stage 3 (2016) includes improved outcomes. The meaningful use objectives are categorized into five patient driven-domains such as:

  • Enhance quality, safety, efficiency
  • Encourage engagement with patients and families
  • Enhance care coordination
  • Improve public and population health
  • Ensure the privacy and security of Personal Health Information (PHI)

In order to achieve the objective in any of these categories, it is very important to adhere strictly to these five quality principles.

Not only should you care about the quality principles, but also be well-aware of the following factors that affect quality documentation.

  • Verbal communication skills of the author
  • Experience of the medical transcription staff
  • Technical issues with the voice equipment
  • Missed, incomplete, or erroneous demographic details of the patient
  • Availability of up to date and complete account specification sheets
  • Hard copy and web-based sources (for example, word lists, dictionaries) useful for transcriptionists
  • Quality Enhancing Software such as Electronic spell checkers and Text expansion software

In short, to eliminate medical errors and provide quality care, healthcare professionals should integrate the above mentioned principles into their quality practices whether they have teamed up with a medical transcription service provider or use in-house transcription.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.