Evaluation Methods for Healthcare Clinical Documentation
Characteristics of Evaluation Methods
The following points highlight crucial aspects of evaluating clinical documentation in healthcare:
- Any evaluation process should involve and educate all members of the healthcare team.
- Seeking healthcare documentation that meets minimum design characteristics clearly allows for evaluation, such as being accessible, having a unique identification number, size and design standardization, and being properly written and organized.
- The evaluation process must be continuous, and the healthcare documentation received should be systematically revised, considering specific parameters. For example:
- Correct order of documents
- Degree of utilization of documents
- Presence of healthcare documentation in hospital admissions (ID folder, history sheet, evolution sheet, surgical and anesthesia intervention sheet, clinical discharge report).
- Most medical evaluation systems are based on reviewing the content of clinical documentation, checking that such collected information is correct.
- Any system evaluating clinical documentation needs to consider and assess proposals for new documents requested by various departments and/or hospital units, trying to solve the needs presented.
Types of Programs and Methods of Evaluation
The ultimate goal of assessment programs is not only to demonstrate existing problems and propose solutions, but also to produce appropriate changes in clinical documentation that ultimately improve the quality of care.
Types of Evaluation Programs
Evaluation programs can be categorized as:
- Internal (Intraorganizational)
- External (Supra-organizational)
External Evaluation Programs
Among external evaluation programs, accreditation programs are noted for their importance and significance, particularly for teaching. Accreditation means professional recognition and public acknowledgment that the health services provided by a particular institution are of high quality. Teaching accreditation is the recognition of the capacity for teaching, which, in the case of health institutions, is associated with a high quality of care.
Basic Elements of an Accreditation Program
- Body: In Spain, these are Accreditation Commissions of a governmental nature, such as the Accreditation Commission for MIR teaching, and the Accreditation Commission for hospital quality in Catalonia. The world’s most prestigious commission for assessment and accreditation is the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) in the USA (a private entity).
- Explicit definition of variables: Variables to be considered when applying for accreditation. In our case, an important variable is the proper generation of a highly-valued clinical discharge report. Other variables include hospital service organization and the existence of quality assessment programs.
- Evaluation Team: An evaluation team visits the institution applying for accreditation. It must be a multidisciplinary team (in our case: doctors, document specialists, nurses, superior health documentation technicians) based on the principle of peer review.
Internal Evaluation Programs
Internal evaluations are conducted at each institution by the professionals of the institution itself or by a committee chosen from among them. They are intended to improve the quality of clinical documentation used in health institutions to improve the care provided to patients. Assessment programs should not be imposed, but should involve all components of the hospital service to be evaluated and obtain the motivation and training of the professionals of said institution.