Healthcare Documentation Integrity Auditing Best Practices
The Healthcare Documentation Integrity Auditing Best Practices Guide is a must-have resource for any
person or facility considering, implementing, or fine-tuning a formal Document Integrity program. The guide provides a standardized approach to all aspects of the program from start to finish, while leaving ample room for facility-specific customization. Training considerations and resource requirements are an invaluable part of that plan. The auditing process is covered in detail, as is the need for a quality assurance process and plan for continuous process improvement.
The Healthcare Documentation Integrity Auditing Best Practices Guide has been created by a group of industry experts to assist all users in understanding and implementing this new approach in auditing clinician-created documentation. It provides a set of explanatories, operational tools, training, marking guidelines, samples, and customizable forms that are intended to be adapted by users to their own needs. Although this material is copyrighted, AHDI gives blanket permission to any potential users of the Healthcare Documentation Integrity Auditing Best Practices document to download and employ the contents of the guide. We do ask that, where appropriate, AHDI be credited with the creation of those contents.
Participants
In June 2021 a representative task force comprised of experts and leaders from the industry began working to create this guide, dedicating countless hours and expertise to create this robust resource. Our heartfelt thanks to the entire team, including Patt King, CHDS, AHDI-F, and Julia Dyviniak, CHDS, AHDI-F, co-chairs of the task force who went above and beyond to lead this group. Tina Wilson, AHDI Operations Manager, kept the task force organized and on track while members shared their experiences, asked great questions, and labored over every detail. We also extend our thanks and appreciation to the vetting group who reviewed the final product before Kristin Wall, CHDS, CHDP, AHDI-F, AHDI Programs Manager and Editor, put all the finishing touches on what we are sure is a guide that will aid programs already in place and those yet to come.
Task Force Members
Patt King, CHDS, AHDI-F (co-chair)
Julia Dyviniak, CHDS, AHDI-F (co-chair)
Nina Bell, CHDS
Susan Dooley, MHA, CHDS, CHDP, AHDI-F
Leigh Anne Frame, CHDS, AHDI-F
Jody Gall, RHDS, AHDI-F
Georgia Green, MBA, RHIA, CCS, CPC, CHDS, AHDI-F
Sheila Guston, CHDS, CHDP-A, CHDP-S, AHDI-F
Julie Heilig
Tina Hincka, RHDS, AHDI-F
Michelle Holden, RHIA, CHDS, AHDI-F
Stacy Lehto, CHDS, AHDI-F
Sabine Sawadogo, RHDS
Julie Staal, CHDS, AHDI-F
Diane Tvrdy, CHDS
Joan VanVels, CHDS, AHDI-F
Tina Wilson
Vetting Group
Cyndi Sandusky, CHDS, CHDP, AHDI-F
Jennifer Styer, RHIT
Guide Review and Design
Kristin Wall, CHDS, CHDP, AHDI-F