Though paper-based clinical documentation is transitioning to electronic clinical documentation, a human interface is still relevant to make the technology work optimally and that human interface already exists in the form of skilled healthcare documentation specialists as per the Association for Healthcare Documentation Integrity (AHDI). "Healthcare documentation specialist" is an umbrella term given for transcriptionists, speech recognition editors, QA specialists, and others involved in clinical documentation and data capture. With their knowledge, skills, and experience in patient documentation, these professionals can help physicians in documenting the details of each individual patient.
With the increasing number of patients, chronic diseases, rising compliance and increasing documentation specificity, physicians can get overburdened and may not be able to address their huge documentation needs. According to the AHDI, documentation specialists can help them in the following ways.
- Standardization of medical documents is very important for sharing them within an EHR system. The documentation should support the workflow of the practices as well. Healthcare documentation specialists understand the medical language, clinical practice, data integrity and have vast knowledge regarding the diverse technologies used to capture the data. They are also well-aware of the requirements of HIPAA and HITECH, workflow and processes, and partner with physicians in ensuring flawless clinical documentation.
- Speech recognition technology is ideal for EHR as it can save the time of physicians as they can simply dictate relevant details into the electronic record system. However, there are several quality issues with SRT technology such as the dictation may not be clear enough for the voice recognition software to capture, software may fail to interpret certain accents, grammar or punctuations, dictation may involve contradictory details that need to be resolved and so on. Documentation specialists identify and correct these kinds of errors and ensure the integrity of medical records.
- As the deadline for ICD-10 implementation is approaching, accurate and detailed documentation is essential for medical practices. Documentation specialists can perform quality checks on the required content of a patient encounter and ensure the accuracy of the documentation so as to help coders choose the most appropriate ICD-10 code.
The main job of healthcare documentation specialists involves monitoring the following discrepancies in documentation:
- Wrong patient or wrong content including demographic mismatches
- Wrong provider name
- Wrong dates of service
- Medication dosage errors
- Right/left, male/female inconsistencies
- Incorrect work types
- Medical contradictions
- Missing elements
- Speech recognition errors
They optimize clinician time, coding and revenue efficiencies by ensuring accurate and complete documentation and providing a strong foundation for data integrity.
AHDI puts forward three solutions to improve the quality and potential of documentation specialists in healthcare practices:
- Bring a laser-sharp focus to the essential component of documentation
- Encourage the education of professionals who are specialized in documentation moving into new roles and new processes of documentation
- Hire trained and credentialed documentation specialists for existing and future roles
Healthcare providers relying on transcription companies that provide EHR transcription should make sure that there is a well-trained quality assessment team that can ensure the accuracy of their vital documentation.