Defining Documentation Quality

I’ve been reading a lot of blog posts and articles lately about the many challenges the healthcare industry faces around healthcare documentation. Technology, new regulations, and other factors continue to change how documentation is created and processed, but are those changes for the better? How can we know that the documentation being created is of an acceptable level of quality, who defines what that level of quality is, and who is accountable for documentation quality?

For many years, medical transcriptionists have been subject to quality standards defined by their employers without an industry-wide standard to use as a guide. Today, documentation is generated by many contributors using a variety of methods. In response to changes in document creation workflow, the Association for Healthcare Documentation Integrity (AHDI) partnered with AHIMA in 2010 to develop the “Healthcare Documentation Quality Assessment and Management Best Practices,” which address quality issues…