Process of Quality Assurance in Healthcare Documentation

Quality is an absolute necessity in every work done and it has even more significance in professions like healthcare documentation which play a crucial role in the well-being of patients. Quality can be achieved by adopting a set of actions that are designed to provide a result that the end-user expects. The main aim of the quality assurance process in healthcare documentation companies is to achieve patient care documentation that is accurate, clear and consistent. Quality assurance professionals command great respect for the excellence and perfection they possess. Although quality assessment is critical and necessary, it is not simple and could be controversial at times too. In healthcare documentation, the quality assurance process is done by senior healthcare documentation specialists who have a thorough knowledge of medical terminology and have good experience in transcription.

In the process of quality assurance, the senior transcriptionists do the quality evaluation of the submitted reports for accuracy and prescribed format while filling out the blanks left by the initial transcriptionist and make corrections if necessary. In this process, the transcriptionists may be awarded grades according to their performance. To understand the importance of quality assurance, let’s get a hold of few of the terms related.

Quality assurance (QA): It’s a process that ensures the transcription reports sent to the client are accurate.

Quality assessment or review (QA or QR): The assessment or review of a medical transcriptionist’s completed report to evaluate the quality of work.

Quality assessment score (QAS): A numeric score that is given to a transcriptionist for the work done indicating the accuracy rate.

Quality assurance editor (QAE): The person who does the job of quality assessment or review.

A transcription report may go to the quality assurance editor in three cases. In the first case, when a healthcare documentation specialist has a problem and needs help, the report can be sent to the QAE. This is termed as putting the transcription report ‘on hold’ for QA. In the second case, all the work done by a particular transcriptionist or work for a specific client can be automatically sent to a QAE. In the third case, random quality assessment audits can be performed.

Usually, a new transcriptionist in healthcare documentation companies is put on 100 quality assessment before his/her reports are sent to the client to ensure that only 100% accurate and properly formatted reports are submitted. When the quality assessment editor gets confident about the transcriptionist’s work, his/her work is taken off from 100% QA.

Moving away from a full quality assessment is an accomplishment for all the new transcriptionists as it means that the work is perfect and needs no corrections. Thereafter, only those reports go the QAE that are problematic or a part of the sample sent for QA audits. Though there may be variations in the process of quality assessment in different healthcare documentation companies, it is one of the crucial processes that ensure accurate and consistent reports are sent to the clients.