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5 Ways better point-of-care documentation can improve your QA processes

If the quality level of your patient visit documentation is questionable, your Quality Assurance (QA) staff is probably spending lots of hours cleaning things up in order to keep your agency compliant and prevent billing delays. Poor documentation may also lead to a high number of Outcome and Assessment Information Set (OASIS) or Hospice Item Set (HIS) rejections, thus creating even more work for your QA staff.

The key to ensuring a streamlined QA workflow is to enable clinicians to capture accurate, timely and compliant documentation while with a patient. Agencies that use a point-of-care solution that has built-in checks and balances to help you enforce documentation completeness and compliance have been able to significantly reduce QA staff time and improve productivity.

Here’s how an effective point-of-care documentation solution can improve QA processes and benefit your entire agency:

  1. Maintain compliance – Technology that is automatically updated to account for new clinical and regulatory changes can help minimize the time your QA staff has to spend correcting and updating documentation to keep your agency compliant.
  2. Reduce communication – This is actually a good thing! When documentation is more complete and is available for QA staff to access immediately after a patient visit, there’s less unnecessary follow-up with clinicians to get additional details or documentation on past patient visits. Plus, you can minimize mileage reimbursement by eliminating the need for clinicians to drive to the office to fix the documentation.
  3. Improve OASIS or HIS completion – A system that integrates a patient’s assessment and visit notes helps to ensure timely completion of OASIS or HIS documentation. Cumbersome documentation or notes can delay this process, causing compliance issues and impacting quality scores.
  4. Eliminate bottlenecks – When documentation is completed and sent to the back office at the point of care, or soon after the patient visit, documentation is streaming into QA workflow at a steady pace. If clinicians are waiting to document until the work day is over, QA may be bombarded with documentation to review the following work day, creating a bottleneck. Technology that provides automatic notifications to QA staff when a new OASIS or HIS documentation is ready for review can help staff plan their day to maximize their time.
  5. Enable a proactive approach to compliance – By using technology that has all correct patient information and documentation in one place, an agency can ensure that everyone is on the same page and QA personnel are able to be more proactive when it comes to identifying compliance issues that need to be addressed.
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