Clinician-Created Documentation

Implementation of the electronic health record (EHR) has changed how clinicians create documentation. Although EHR technology is intended to increase efficiency and accuracy, many healthcare organizations are lacking in quality assurance of the documentation being directly entered by clinicians. Sherry Doggett, retired director of Transcription Services for UCHealth in Cincinnati, Ohio, recalls, “I had many conversations with transcription managers who were noting serious quality issues within their respective organizations’ EHR. Further concern for me personally was implementation of the EHR at my organization and noting the same type of errors in clinician-created documentation.”

When Doggett retired from UCHealth last year, she realized her work wasn’t done. “It seemed the next step was a task force to identify the current issues and how best to provide the tools necessary for an effective QA program for clinician-created documentation.” So, in 2013, AHDI and AHIMA convened a joint task force to develop QA best practices and a toolkit for clinician-created documentation.

Julie Dooling, RHIA, director of HIM Practice Excellence at AHIMA, was an active participant with the project. “Unfortunately, many quality assurance (QA) programs have fallen to the wayside with priority being given to EHR implementation using pick lists, templates, or risky practices such as copy/paste. QA programs focusing on clinician-created documentation must be reinstituted to meet the objectives of constructing quality healthcare documentation and ensuring documentation integrity. AHIMA has had a long presence in the industry focused on information integrity and quality documentation.”

The convening of the task force was very timely for Joyce Smith, manager of Transcription/Documentation Integrity Services at Spectrum Health System in Grand Rapids, Mich. “I heard about this task force about the same time that Spectrum Health began a pilot project to deploy Cerner PowerNotes, and I joined hoping to learn what others were doing. When we started looking at the notes the physicians were creating, I knew we needed to add the QA process that the task force was discussing. We began developing tools and spreadsheets as a team and I was actually putting them to the test using a few transcriptionists to begin looking at the notes. By putting the tools into action, we were able to quickly determine what was working well and what needed to be tweaked.”

The task force quickly identified that many healthcare organizations do not realize the potential for quality issues with EHR documentation. “I distinctly remember my first approach to C-suite on the subject of developing a QA program for clinician-created documentation,” recalls Leigh Anne Frame, CMT, AHDI-F, transcription manager at Bryan Medical Center in Lincoln, Neb. “It was met with indifference and was generally followed up with the comment that it was the responsibility of the clinicians to assure accuracy of their reports; end of discussion. I knew at that point that mere talking about it was not going to get me anywhere and that I needed to create a picture that caught their attention. I did that through creating a dashboard that provided them with simple, meaningful information, and we’ve been doing QA on these clinician-created documents ever since.”

Indeed, QA dashboard reporting tools are a large part of the results from the task force so that documentation managers can share issues and progress appropriately. “I believe that the C-suite in a healthcare facility cares about quality documentation,” observes Frame. “I think that sometimes they are just out of touch with the details of the day-to-day operations because they don’t have time to focus on the details. The creation of a dashboard is a visual and effective tool that provides accurate and trusted data, allowing them to see the real picture and focus on process improvement to assure the integrity of the medical record.”

The task force also wrote a white paper and created a presentation that describes the importance of QA separate from the more widely utilized process of clinical documentation improvement (CDI). CDI is typically intended to ensure the accuracy of clinical status like severity of illness, risk of mortality, and complexity of care so that it is translated appropriately into coded data. However, the task force emphasizes that a QA program is the complete review of the narrative and discrete data in a patient’s record for the purposes of protecting the patient, caregivers, and healthcare organization from the legal, compliance, and risk management perspective.

Debra Randolph, CMT, RHIT, manager of HIM Documentation Integrity at Moffitt Cancer Center in Tampa, Fla., advocates for QA as a risk management strategy. “The new QA standards and tools can assist healthcare documentation departments in getting buy-in for an organizational clinician QA program by proving the importance of auditing clinician-created documentation. I think the main thing to remember is that in removing transcription from the picture in most cases is removing a 2-3 step QA process. This process is getting circumvented by the provider creating the document and signing it, signaling the document to go straight to distribution. Patient care is too important to leave this critical step out.”

Beyond reviewing documentation for errors, blanks, and inconsistencies, the QA program can become a process improvement initiative that impacts the entire organization. Lisa Woodley, RHIT, CMT, manager of Record Integrity and Transcription at Virginia Mason Medical Center in Seattle, Wash., sees the QA standards created by the task force as a benefit to everyone involved. “I think that standards can only help documentation process improvement initiatives in any organization. At Virginia Mason, process improvement and standardization are part and parcel of everything we do. From that perspective, having standardized documentation only makes sense. It gives the provider/staff member clear guidelines and the right tools so they can easily do the right thing and it prevents complication and second guessing when information is unclear or nonstandard. Ultimately, it provides for better patient care and increased patient safety, by making sure that everyone involved in a patient’s care has the right information, in the right way, at the right time.”

The AHDI/AHIMA QA Task Force recently completed a comment period on the draft standards and tools and will be releasing the final best practices as part of a QA Summit on “Clinician-Created Documentation: The Reinstitution of the QA Program” at AHDI’s Healthcare Documentation Integrity Conference on Friday, July 25 in Las Vegas. To learn more, visit

Jill Devrick is Product Solutions Advisor, eHealth Documentation Solutions, 3M Health Information Systems.

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