Quality Assurance for Health Care Documentation

Health Care Documentation
Quality in health care documentation is crucial when it comes to ensuring proper and timely health care. In view of this, the Association for Healthcare Documentation Integrity (AHDI) has paid down best practices to assure quality, timeliness and security in medical transcription reports. Here are the main elements of a comprehensive quality assurance program:

  • Proactive: The program should be devised in such a way that it can handle problems before they occur as prevention is always better than cure. This would improve efficiency and assure better patient care.
  • Easy and simple to implement: The quality assurance program should be simple and easy to understand to ensure proper implementation.
  • Safe and confidential: When it comes to feedback, the overall processes must be HIPAA-compliant and meet the necessary privacy and security guidelines. Processes should also be compliant with state laws and department or facility requirements.
  • Educational: Constructive feedback is the highlight of quality assurance as it supports positive information exchange and encourages quality improvement.
  • Sensible and financially practical: The process needs to be practically achievable by both small and big medical transcription service providers.
  • Reportable: The quality process must have methods of tracking and reporting trends so that areas needing improvement can be identified.
  • Assessment within day-to-day processes: Quality assessments on a consistent and daily basis would ensure timely feedback for enhanced quality.
  • Coverage of entire author-to-text process: The program must comprehensively cover all the phases of documentation – authors, medical transcriptionists, quality personnel, equipment, software, and workflow processes.

The key to integrity in healthcare documentation is a successful partnership between healthcare provider who dictates the report and the transcriptionist who transcribes and edits it. Established medical transcription companies set up and implement impressive programs based on the above aspects to ensure quality in medical documentation.

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.