Quality Matters—Auditing Records in the EHR (1 TT)

Presenter: Stacy Lehto, CHDS

Bio: Stacy is a certified healthcare documentation specialist who has worked in the industry for over 23 years with experience in transcription, QA, editing, and her current role as Senior Healthcare Documentation Quality Analyst at Spectrum Health in Grand Rapids, MI. She is a member of AHDI. She has worked with AHDI on several projects including being on the Board of Directors and working on committees such as BOSS4CD Development Team, Conference Program Committee, Virtual Conference, and Strategy Task Force. She also did copy editing projects for Stedman’s on several books, including the Medical Transcription Skill Builder series. 

Session Description: 

Auditing medical records in an EHR can be tricky and a bit overwhelming, especially since there is no voice for comparison. This webinar will touch on the auditing process, finding and documenting potential critical errors, and how to verify and compare information in the EHR (such as labs, medications, histories, and demographics) with the content of the document. Auditing requires an understanding of the patient’s story, not just reading the words in the document. Attention to details such as inconsistencies, wrong medical words, wrong dosages, demographic errors, and things that simply do not seem “right” will be discussed.

Learning Objectives
    1. Understand the importance of auditing medical documents (H&Ps, Consults, Op Notes, ED Notes) in an EHR to assess for accuracy of the record. 
    2. Understand the definition of critical errors. 
    3. Learn how to find and verify potential critical errors within a document.
    4. Navigate within the EHR to verify errors.