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Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers

RESOURCE KIT

In July 2014, AHDI and AHIMA released Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers. This document provides a standardized approach to measuring, reporting, and improving documentation for patient safety and documentation accuracy when clinicians are responsible for document creation. The Resource Kit, which is available below, provides the tools needed to create and implement a quality assurance program in healthcare organizations.

The Resource Kit provides a set of explanatory and operational tools that are intended to be adapted by users to their own needs. Although this material is copyrighted, AHDI and AHIMA give blanket permission to any potential users of the Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers document to download and employ the contents of the Resource Kit. We do ask that, where appropriate, AHDI and AHIMA be credited with the creation of those contents.

Resource Kit:

PowerPoint Presentation

QA Program Checklist (MS Word)

QA Program Sample Policies and Procedures (MS Word)

QA Categories (MS Word)

QA Review Form and Sample (MS Word)

Dashboard Best Practices (MS Word)

Dashboard Templates and Samples (MS Excel)

Model Job Descriptions (MS Word)

Video Tutorial (COMING SOON!)

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Definitions Minimize

Working definition of “Clinician-Created Documentation”: 
 
Medical documentation that is created by a clinician.  This type of documentation is created using a combination of front-end speech recognition, drop down menus, or templates in electronic health records. 

 

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