Documentation Quality: The Least Measured Metric in Your Department


Let’s start with the obvious.  If patient care is the single most important result of documentation, then documentation MUST be accurate. Is a 98% accuracy level acceptable?  I was usually happy with a test score of 98% in high school, but medical documentation should be held to a different standard.  What about that 2%?  Is it okay for 2% of reports to have critical errors that affect the treatment a patient will receive?  Or is it okay if 2% of the details in a report are incorrect as long as 98% are right?

What is the tipping point for quality in healthcare documentation?  What is an acceptable error rate?  Personally, I think the acceptable error rate is 0%.  I want perfection in my reports!  I want to know that my doctor cares enough about me and my health to make sure that the documentation in my charts is correct and error-free.  I want to feel confident that my medications are listed correctly, that my relevant past medical history is documented and that the weight listed is accurate to the quarter-ounce.

So how do physicians maintain documentation perfection with everything else that has been put on their plates?  How can they strive for perfection while working 55 to 96 hours each week?  How do they pay attention to the smallest details in every single report?  The answer is … they cannot.  However, they can get very close over time.  Think of Michael Jordan, the basketball player.  He didn’t start out as a superstar; in fact, he was cut from his high school basketball team!  But Michael Jordan is considered one of the best – if not the very best – professional basketball player of all time.  What did he do to get there?  How did he improve his accuracy?  Practice, practice, practice.  He listened to his coaches, worked on perfecting his shots and improved over time until he was the very best.

Self-editing medical reports are no different.  Physicians need to be trained properly, and they need coaching to point out their errors and bad habits.  They need to practice identifying the best ways to dictate and the best ways to edit their reports.  They need to look for ways to improve their accuracy and to increase their productivity.  They need to be shown the proper way to edit, and they need to be able to measure their effectiveness.

SpeechCheck has the expertise and experience to help physicians improve the quality of their documentation – and measure their progress over time.  Haven’t we waited long enough to increase our expectations of documentation quality?

Posted by: SpeechCheck

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