Quality Assurance
Healthcare Documentation Quality Assessment and Management Best Practices (updated July 2017)
Whitepaper & Toolkit
In July 2017 the Healthcare Documentation Quality Assessment and Management Best Practices toolkit was updated and also combined with information and resources from the Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers resource kit, which addressed the absence of quality assurance programs in electronic health record documentation processes.
Clinician-created documentation comprises a greater percentage of the healthcare record than in the past, yet traditional transcription still holds an important role as a documentation practice that many clinicians are unwilling to relinquish. Both front-end and back-end speech recognition are widely used, yet careful review and editing by the healthcare documentation specialist (HDS) and by the clinician are required to achieve optimal results. As new trends and roles become more firmly established, the need for a unified set of standards in quality assessment, one that is applicable for both HDS-created and clinician-created documentation, has become pronounced, both from the perspective of the equivalency of errors being made and for ease of use by the quality assurance workforce. It is for this reason that the AHDI quality assurance best practices of 2010-2011 and the clinician-created documentation quality assurance program of 2014 have been combined in this new toolkit of best practices for all.
Although this material is copyrighted, AHDI and AHIMA give blanket permission to any potential users of the Healthcare Documentation Quality Assessment and Management Best Practices document to download and employ the contents of the toolkit. We do ask that, where appropriate, AHDI and AHIMA be credited with the creation of those contents.
Download the Toolkit
Healthcare Documentation Quality Assessment and Management Best Practices (PDF) – A comprehensive revision of standards and best practices in healthcare documentation quality assessment and management. This information provides a standardized approach to measuring, reporting, and improving documentation for patient safety and documentation accuracy. Moreover, fundamental principles of quality in healthcare documentation are reevaluated and revised in light of the new technological and policy environments of the 21st century.
Supplementary Toolkit Resources
Why Combine QA and CCD Best Practices? (PDF)
QA Program Checklist (MS Word worksheets)
CCD QA Program Sample Policies and Procedures (MS Word)
HDS QA Program Sample Policies and Procedures (MS Word)
CCDI Case Study (Spectrum Health) (PDF)
QA Review Form and Sample (MS Word)
Dashboard Best Practices (PDF)
Dashboard Templates and Samples (MS Excel)
Error Values, Definitions, and Examples (PDF)
Sample Department Annual QA Performance Metrics (MS Excel)
Sample HDS Annual QA Performance Metrics (MS Excel)
Sample QA Score Sheet 1 (errors divided by number of lines method) (MS Word)
Sample QA Score Sheet 2 (error value from 100 method) (MS Word)
Statistically Valid Sampling Techniques and Calculations (MS Word)
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).
What Users are Saying
“The AHDI QA Best Practices for Clinician Created Documentation toolkit has been a wonderful tool! It has helped us to set up a QA program for this, along with guidelines as to what are critical errors and noncritical errors. Our program changes weekly, but we are finding better ways to do things. Some of the changes aren’t very big but, as it evolves, it is only getting better. Hopefully we will have a solid program in place within 6 months!” – Ardyce Heffernan, CHDS