As the national discussion about the electronic health record (EHR) continues, it becomes clear that in order for the EHR's promises of improved patient care and decreased healthcare costs to be realized, quality assessment and management must be prominent features of the documentation landscape. The Association for Healthcare Documentation Integrity (AHDI), demonstrating and supporting the critical quality-assessment role of medical transcriptionists, continues to develop new strategies and tools for ensuring quality documentation by directly addressing quality assurance (QA) program standards and design (in partnership with the Clinical Documentation Industry Association [CDIA] and the American Health Information Management Association [AHIMA]) and by setting high standards in our credentialing for the transcription workforce. 

Recent "AHDI Track" articles have described the 2010 Healthcare Documentation Quality Assessment and Management Best Practices standard (Quality Takes on New Meaning, Tools May Help) and the new association standards and examinations for credentialing introduced in 2011 (Credentialing for MTs Takes on New Look, New Policies). AHDI staff and teams of dedicated volunteers have followed up those achievements by developing tools to assist in the implementation of the new standards for quality assessment and credentialing: the Healthcare Documentation Quality Assessment Best Practices Tool Kit, the RMT Exam Guide and the CMT Exam Guide.  

The QA Best Practices Tool Kit is designed to provide medical transcriptionists, transcription managers and supervisors, HIM managers and supervisors, practice managers, medical transcription service organizations (MTSOs) and others with a set of operational tools for implementing and managing quality assurance programs under the guidance of the best practices standard. The Tool Kit, which is a free download at the AHDI website, contains five individual tools that can be adapted to the unique needs of each healthcare facility or service organization. 

Within the Tool Kit a handout titled "Why the Changes?" provides a 1-page summary of the rationale for the creation of a new quality assessment and management standard. The "Adoption Guide" is a detailed narrative containing suggestions for an implementation program for the best practices standard. This program (like the Best Practices Standard) is based on the continuous quality improvement four-step management process Plan, Do, Check and Act (PDCA) developed by management expert W. E. Deming. It establishes a flexible framework that can be used in a variety of environments and adapted to specific organizational needs. A "QA Best Practices" Power Point presentation summarizes the contents and organization of the Best Practices Standard document. This presentation can be used to introduce QA best practices to administrators, clients, transcriptionists and others involved in the documentation process, and the material in the slides can be used to build out more extensive discussion as appropriate to particular settings. The 14 "Checklists" are flexible tools that link to specific operations and implementation steps in the Adoption Guide. They are designed to be customized by QA Best Practices users to fit their own environments and needs. Finally, the "Scoring Spreadsheet" provides the basis for creating user-specific sets of quality assessment records to document quality assessment procedures and results for individual medical transcriptionists.

A second essential building block for quality in healthcare documentation is credentialing of all workers involved in the documentation process, and AHDI continues to strengthen our credentialing program in support of this goal. The 2011 publication of the RMT Exam Guide and the CMT Exam Guide provides credentialing exam candidates with key information about the structure and content of the newly redesigned RMT and CMT examinations. These guides, each subtitled A Walk through the Blue Print, focus on the cognitive assessment (multiple-choice) portions of the exams, with introductory material covering specific content areas in the 2011 exam blue prints. The guides also present exam objectives as they are written in the blue prints, and the rationale for those objectives. For each objective in each content area, the guides offer sample questions that demonstrate what candidates are going to see on the exams. Each guide also includes a practice exam that reproduces the structure of the exam itself in terms of content and number of questions.  

The Guides do not substitute for the solid basic education required for success in the RMT exam, cannot replace the 2 years of acute-care experience required for the CMT exam, and do not replace the content reviews provided by a number of vendors (such as Stedman's and Oak Horizons). Rather, the intent of the RMT and CMT guides is to provide a foundation upon which candidates can orient and organize all their preparatory efforts.  The guides are available at the AHDI website, http://www.ahdionline.org/Home/tabid/37/Default.aspx.

In summary, the Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit, the RMT Exam Guide and the CMT Exam Guide support and promote the contributions that medical transcriptionists can make to quality documentation, whatever the environment in which records are created. 

Dr. Rebecca McSwain serves the health documentation industry as Professional Practices Associate at AHDI.  She is an educator, researcher and writer, and a medical transcriptionist with more than 30 years of acute care, clinic and office experience. She has worked as an on-site and home-based production MT, supervisor and QA manager. She has been an adjunct college instructor since 1990 and for 5 years authored the column "Transcription Zone" for the online edition of Advance for Health Information Professionals. Rebecca has also written for The Journal of AHIMA and the print edition of ADVANCE. Rebecca's PhD is in anthropology, and she has written for academic journals and books on anthropological topics.