Healthcare Documentation Creation Best Practices Toolkit

The Association for Healthcare Documentation Integrity (AHDI) is actively engaged in offering our professional expertise to address the impact of problem healthcare documentation as it relates to documentation errors and critical flaws that can adversely impact patient safety, alter patient care of treatment, adversely impact the accuracy of coding and billing, result in a HIPAA violation, and adversely affect medicolegal outcomes.

With the many technical changes in healthcare documentation creation, the Healthcare Documentation Creation Best Practices toolkit has been updated to address these evolving practices. Included are tips for dictation best practices as well as best practices for EHR documentation creation using templates, front-end speech, drop-down menus, etc.

The Healthcare Documentation Creation Best Practices toolkit is designed to assist facilities with the adoption and implementation of policies and training practices that will promote and ensure the best documentation outcomes. This kit includes the rationale for promoting better dictation and documentation practices, including A Note to Users discussing the increased risk for errors to be introduced with the multiple ways in which healthcare records are created, which may affect patient safety and documentation integrity. The Dictation Quick Reference and Tip Sheet by Documentation Type provide simple but important recommendations and reminders of good dictation habits, which will reduce errors or missing information in documentation and potential delays in the delivery of patient records. In addition, this toolkit provides a Sample Orientation Procedure for New Dictators, as well as recommendations for Working with an MTSO. Visual aids include Cue Cards, a Dictation Card Sample, and a Phonetic Alphabet chart.

Toolkit Downloads

A Note to Users from AHDI – A welcome letter from the association and rationale for promoting better dictation and documentation practices.

Sample Orientation Procedure for New Dictators – This document is designed to assist the trainer/educator in conducting a quick training session with new dictators on the purpose of clinical documentation, fundamentals of best practices, as well as facility-specific and/or equipment-specific processes.

Dictation Quick Reference – A handy resource document that outlines recommendations and reminders of better dictation habits.

Tip Sheet for Documentation by Type – A take-away handout for clinicians/authors dictation and documentation tips listed by type of entry (e.g., Direct Entry, Partial Dictation, Front-End Speech Recognition) to help eliminate errors in documentation. This tip sheet can also be posted in designated dictation areas and physician offices to communicate your goals for best practices in dictation. Note: AHDI strongly recommends facilities modify/customize this tip sheet to reflect facility-specific guidelines, equipment specifications, policies, and procedures to ensure that application of these tips best meets the needs of your organization.

Sample “Q” Cards for Dictators – We recommend providing quality cards (Q cards) to dictators for quick wallet access when dictating from facility dictate stations or remotely from another access point. This document provides a sample of what such a resource could look like for your organization, with equipment procedures on one side of the foldable 4-panel card and document types and formats on the other side.

Dictation Card Sample – This sample card outlines dictation instructions and should be posted at every dictation station. Such a card should be customized based on the an organization’s dictation system and procedures to be followed.

Strategies for Working with MTSOs – A resource document for facilities and transcription services owners working together who, by the nature of their contractual relationship, may or may not have direct access to providers for the purpose of addressing dictation concerns. This document provides tips for how to address this contractually as well as strategies for working with facility contacts and clients to improve dictation practices.

Phonetic Alphabet – This chart provides common code words assigned to the letters of the English alphabet so that letters can be pronounced and understood clearly, which is critical for accuracy in spelling patient names and soundalikes of terminology.

If you have any questions about how to integrate any of these toolkit pieces into your organization or have suggestions or feedback for future editions of this kit, please contact AHDI (pubs@ahdionline.org).

Acknowledgements

Thank you to the following people who helped with the creation and revision of this toolkit:

Sherry Doggett
Patt King
Suzanne Mabie