The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.
As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA(now CDIA) and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.
Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.
Plan: Planning policy guidelines for quality
This part of best practices for maintaining quality involves a set of standards for documentation that ensures accuracy, accessibility and overall value of the patient medical record as a resource for understanding the care process including diagnosis, treatment and progress.
To ensure this, the planning process should have principles that ensure:
- Verifiability: Any quality program should have standards and measures that are easily verifiable and these measures should be available to personnel at every level of the organization and to the end user of the transcript to ensure cross verification
- Definability: The error categories should be clearly defined
- Measurability: Measurable values for clearly defined error categories should be assigned and measurement methodology for errors should be clear to all the parties involved
- Consistency: The quality program should define error categories, values to be assigned to each category and there should be a standard method error determination.
- Integrity: The integrity of document can only be assured when there is a synchronized partnership between the originator of dictation and the medical transcriptionist. The healthcare professional dictating the notes should present information in a clear and concise manner and the medical transcriptionist should transcribe the document preserving the essence of the information provided by the healthcare professional
To this end the quality assurance program should be based on Quality Guidelines that ensure the following:
- Accurate and complete documentation ensuring that the essence of the encounter is captured
- A process of distribution of reports on a timely basis and a system for easy accessibility of past records to the relevant personnel
- A practice of periodical quality audits to study the process and assess where errors occur as a part of the ongoing quality process
- This process to be applied to medical transcription at all levels
- The assessment program should be consistent and unbiased
- The assessment program should be according to the principles of assessment agreed upon
- The results from the assessment process to be used as a learning tool to ensure recurrence of errors
- Access to the Quality Guidelines, assessment process to be made available to all the people involved in the transcription process.
To be successful a quality assurance program should be:
Proactive: Medical transcription being such a critical activity that contributes to the healthcare process, it is important for quality assurance program for medical transcription to be proactive. Being proactive ensures that solutions are available for problems before they turn into major issues
Realistic, scalable and financially feasible: Quality in medical transcription is a continuous process; therefore it is important that the quality assurance program should be realistic and cost effective
Simple and easy to implement: Medical transcription is a process that consistently needs to meet the quality constraints of accuracy and timeliness, keeping this in mind any quality assurance process has to be simple to be workable.
Secure and Confidential: Considering that medical transcription involves working with confidential patient information and comes under the purview of HIPAA it is important that any feedback regarding quality keeps in mind the confidentiality norms
Inclusive of all aspects: Quality in the medical transcription process involves all aspects starting from the origin of the data down to the medical transcriptionist, proofreader and quality team, the quality assurance program needs to plan measures to include all these aspects
Reportable for trending and tracking purposes: The process of quality assurance is not only to ensure consistent quality documentation but is also a valuable input for education purposes
Timely: The quality assurance process should be scheduled in timely manner to ensure maximum results
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