The Importance of Quality in Health Records Essay

The Importance of Quality in Health Records - Essay Example Notably, there are strict laws that guarantee the confidentiality of the information processed in the health records. Moreover, quality matters in health records. Indeed, accurate and complete clinical documentation of health records define the quality of health records. A quality audit of health records refers to the process of conducting internal or external reviews of all the tools, policies, procedures, and techniques used in healthcare institutions to ensure that the health records are up-to-date, accurate, efficient (Holmboe, n.y), liability-free, and compliant with the federal and the Department of Health standards. A quality audit seeks to improve clinical documentation with an aim of promoting better delivery of health care as well as ensuring efficiency and accuracy in documentation. Moreover, it establishes the medical areas that need improvements and corrections (Sharma & Mahajan, 1999). The conduct of a quality audit follows various steps. It can adopt an explicit or an implicit approach. However, the explicit approach is highly recommended (Holmboe, n.y). An understanding of the audit process is fundamental in assessing the quality of medical records. Notably, quality audits focus on and evaluate the procedural and diagnosis code selection adopted by a health practitioner. Firstly, the reviewer determines the educational and evaluation purpose of the audit. He then chooses and defines the quality measures in application. Additionally, he describes the audit process with well-defined inclusion and exclusion criteria. Then, he establishes the areas of weakness, presents the audit findings, and establishes the areas of improvement and corrections in collection and processing health records. Most assuredly, the steps in the audit process determine the quality of the audit (Holmboe, n.y). The quality of documents in healthcare is very important. Various methods assure quality in documents. They include the requirement for authorization to