In health care, accuracy and timeliness are critical for data entry and medical transcription. There can be no compromise as errors can even mean the difference between life and death. For instance, wrongly entered medication dosage can lead to medications administered in the wrong amounts and at the wrong frequency, which could have life threatening consequences. The key aspects of medical data quality are:
Many physicians’ practices currently rely on electronic health record (EHR) integrated medical transcription services to meet their data and documentation quality goals. Let’s look into the essential characteristics of medical data and the various controls that health care providers need to adopt to ensure quality.
Timeliness: Timeliness means that the data should be recorded within an appropriate time frame, typically as it is being collected. If the nurse monitors a patient at 5pm, the note in the patient record should be written soon after that and preferably at the point-of-care. Surgeons need to record operative notes shortly after the surgery and not weeks later.
According to The Joint Commission’s 2012 accreditation standards, an operative report must be documented immediately after the operation. The Federal Register (2012) recommends that a history and physical must be dictated and present in the health record within 24 hours of admission or before an operation. The Joint Commission and Conditions of Participation (COP) standards recommend that following a patient’s discharge from an acute care facility, the record must be completed within a specified time, usually 30 days. If state licensing law recommends a shorter time frame, this should be given precedence.
Medical transcription service companies play an important role in ensuring timely medical documentation by providing transcripts of healthcare providers’ dictation in custom TAT. They also offer several convenient options for dictation such as toll-free phone-in, digital recording, smartphones and conference calls.
Completeness: Complete data is necessary to support patient care. Completeness refers to collection or recording of all relevant medical data including vital signs such as blood pressure heart rate, respiration rate, temperature, neck and head exam, neurological exam, dermatological exam, and physical and sensory changes. A record would be considered incomplete if any vital sign or data had been missed out and if the time and date has not been entered. For a progress note to be complete, it must be authenticated.
Accuracy: This means avoiding errors in data entry. An article published by Modern Healthcare in February noted that electronic health records (EHRs) are breeding grounds for wrong data entry due to confusing computer displays. This could lead to errors such as ordering the wrong medications or missing key patient information.
In order to ensure that the data collected is timely and complete, health care providers need to develop and implement data quality controls. These include preventive controls, processing controls and corrective controls.
Preventive controls refer to procedures, processes or structures developed to minimize errors at the point of data collection. Examples include software alerts when date is entered wrongly or verbally identifying the patient before taking a blood sample. Drop-down menus in EHRs are designed to prevent invalid data entries. However, the errors can occur if the physician selects the wrong item.
Processing controls help discovery of errors through quantitative analysis and error reports which highlight mistakes as well as omissions. Corrective controls involve correction of errors that have been discovered. The problem is that certain errors such as the administration of a wrong medication cannot be corrected. So the source of the error must be investigated to prevent future occurrence.
Outsourcing medical transcription is a practical option when it comes to avoiding clinical documentation errors. Reliable companies have stringent quality control measures in place to ensure documentation of physician dictation with up to 99% accuracy.