Volume 1

A Common Definition

Previous Chapter | Next Chapter: A Meeting of the Minds, or Who Is Responsible

We often use the phrase high quality clinical documentation loosely. What one hospital or group defines as high quality clinical documentation may be quite different from another. The term, quality, according to Six Sigma principles is subjective to an extent since quality is to be determined by the customer. In chapter 6, a definition of high quality clinical documentation, derived from official and quasi-official resources like CMS, the Joint Commission, and the American Health Information Management Association (AHIMA), is provided. In addition, the application of this definition to actual documentation scenarios is briefly described. This definition is minimum data set for high quality clinical documentation. It is documentation that is timely, legible, complete, reliable, clear, consistent (unambiguous), and precise.

The voice of the customer – including patients, health plans, governmental and accrediting bodies, and even physicians – defines quality.  You can use physicians to help educate patients about their medical records, creating a common synergy that you can use to discover what both patients and physicians are looking for in health information.

Chapter 6 describes how to explain the mandatory minimum to all interested parties and then work together to determine what (if anything) needs to be added to the definition to ensure your organization’s program is consistent with your VVMS. Identifying all customers for health information is discussed, and solutions as well as proven case studies, are presented. There is no one right way to approach these complex issues. But, minimum official guidelines together with suggestions for teaming and examples of how other organizations have succeeded are combined to help your organization thrive.