Quality Assurance
Healthcare Documentation Quality Assessment and Management Best Practices (updated June 2025)
White Paper & Toolkit
In June 2025, AHDI’s Healthcare Documentation Quality Assessment and Management Best Practices Toolkit was updated to reflect today’s rapidly evolving healthcare documentation environment. The previous version, dated 2017, included quality assurance of clinician-created documentation. This content has been removed and is now available as a dedicated resource in the Healthcare Documentation Integrity Auditing Best Practices. The Healthcare Documentation Quality Assessment and Management Best Practices Toolkit was originally developed to address the lack of structured quality assurance (QA) processes in healthcare documentation. This resource has been updated and maintained over the years to stay current with quality assessment needs to uphold the highest standards of documentation excellence.
Although this material is copyrighted, AHDI and AHIMA give blanket permission to any potential users of the Healthcare Documentation Quality Assessment and Management Best Practices document to download and employ the contents of the toolkit. We do ask that, where appropriate, AHDI and AHIMA be credited with the creation of those contents.
Download the Toolkit
Healthcare Documentation Quality Assessment and Management Best Practices (PDF) – This revised 2025 edition delivers an up-to-date framework for assessing and managing documentation quality across healthcare environments. It introduces enhanced standards and methodologies designed to improve accuracy, accountability, and patient safety in a rapidly evolving digital landscape. The revision reflects advances in technology, workflows, and best practice policies, offering a unified, industry-wide approach to quality measurement and continuous improvement.
Supplementary Toolkit Resources
QA Program Checklist (MS Word worksheets)
HDS QA Program Sample Policies and Procedures (MS Word)
Reporting Best Practices (PDF)
Sample Department Annual QA Performance Metrics (MS Excel)
Sample HDS Annual QA Performance Metrics (MS Excel)
Sample QA Score Sheet 1 (errors divided by number of lines method) (MS Word)
Sample QA Score Sheet 2 (error value from 100 method) (MS Word)
QA Scoring Worksheet (MS Excel)
If you have any questions about how to integrate any of these toolkit pieces into your organization or have suggestions or feedback for future editions of this kit, please contact AHDI (ahdi@ahdionline.org).