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Transcript of QA of EHR Documentation: The Quest for Quality beyond CDI · QA of EHR Documentation: The Quest for...
QA of EHR Documentation: The Quest for Quality beyond CDI
Jill Devrick, MPA Past President, AHDI National Leadership Board
Product Manager, 3M Health Information Systems
Modes of Documentation Capture
• Handwritten notes
• Dictation and transcription – paper
• Dictation and transcription – electronic
• Speech recognition technology
• Templates in the electronic health record
• Clinician mobile devices
Why Create Documentation?
• Continuity of patient care
• Information sharing
• Legal due diligence
• Financial justification
• Research
• Clinical decision support
The Way We Were
Chart EHR/EMR
Patients Clinical Colleagues
Office Staff Insurance Companies
Legal/Compliance/Risk HIM/CDI/Coding
HIT Physician
Healthcare Documentation Specialist
Sign
ed D
ocu
men
tati
on
The Way We Are
Chart EHR/EMR
Patients Clinical Colleagues
Office Staff Insurance Companies
Legal/Compliance/Risk HIM/CDI/Coding
HIT Physician
Sign
ed D
ocu
men
tati
on
6
Risks of Unmonitored
EHR Documentation
Practices
Patient Safety
Financial Impact
Compliance Issues
Legal Consequences
7
A Quality Assurance (QA) program
is NOT a Clinical Documentation Improvement (CDI)
program.
QA CDI
• A CDI program facilitates the accurate representation of a patient’s clinical status (severity of illness, risk of mortality, complexity of care) that translates into coded data.
• A QA program is the COMPLETE REVIEW of the narrative and demographic data to protect the patient, caregiver(s), and the organization’s documentation integrity.
CDI vs. QA
Organizations should incorporate BOTH
programs to ensure compliance throughout the healthcare continuum.
9
QA AND CDI
Common EHR Practices That Create Vulnerabilities
1. Copy and paste or “note bloat”
2. Lack of review, correction, and feedback
3. Unmanaged/inconsistent template creation and modification
4. System(s) designed and built with limited healthcare documentation expertise
Additional Vulnerabilities
1. Inappropriate abbreviations
2. Inappropriate templates
3. Wrong patient/wrong visit
4. Incorrect check box selection
5. Speech “wrecks”
Best practices should be used to protect the integrity of the patient’s health information.
The HEART of the matter = PATIENT SAFETY
Fraud is not the only concern.
ACCURATE CLINICAL
DOCUMENTATION
Fewer Medication Errors
•Appropriate medical care
•Continuous care
Improved Management
•System errors detected
•Accurate data abstracted and submitted
Appropriate Funding
•Equitable resource allocation
•Improved regional planning
The Role of the Healthcare Documentation Specialist
1. Produces documentation that reflects the patient’s story in a correct, complete, and consistent manner
2. Ensures accurate documentation
3. Creates a business record that can be trusted and referenced
• Reviews content and provides feedback to clinician
• Develops and maintains template design program
• Trains clinicians on template usage
• Collaborates with key stakeholders
• Includes the patient whenever possible
• Strives for continuous quality improvement
The Role of the Healthcare Documentation Specialist
• Reviews and flags documentation Validates patient and visit demographics Flags critical errors for correction Identifies minor errors
• Provides feedback to the originating clinician Safety net (“second set of eyes”) Educational opportunity for the reviewer Pre-CDI content review to assist with coding and
reimbursement and template creation
The Role of the Healthcare Documentation Specialist
Clinician-Created Documentation Tool Kit
• “Why?” White Paper
• QA Error Categories
• PowerPoint Presentation
• QA Program Checklist
• QA Program Policy/Procedure
• Model Job Descriptions
• Trending/Tracking Spreadsheets with Examples
• Trending/Tracking Spreadsheet Template
• Clinician-Created Documentation Review Form
• Clinician-Created Documentation Review Sample with Errors
• Clinician-Created Master QA Form
• Dashboard Examples
• Dashboard Templates
• Dashboard Best Practices
• Video Tutorial for PowerPoint Presentation
Clinician-Created Documentation Tool Kit
Recommended EHR QA Best Practices
• QA all content generated by speech recognition
• Develop and maintain a template design program
• Train clinicians on template use
• Collaborate with HIM, HIT, HDS
• Include patient when possible
• Strive for continuous documentation improvement
QUESTIONS
Jill Devrick, MPA Past President, Association for Healthcare Documentation Integrity
Product Manager, 3M Health Information Systems [email protected]
Resources
A Guide to Better Physician Documentation
AHDI/MTIA/AHIMA Healthcare Documentation Quality Assessment and Management Best Practices
AHIMA Copy and Paste Position Statement
Dimick, Chris. "Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk." Journal of AHIMA 79, no.6 (June 2008): 40-43.
The Joint Commission - Most Challenging Requirements in 2013