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When In Doubt, Write It Down: Documentation a Common Deficiency in Accreditation Surveys

By Naomi Kuznets, Belle Lerner and Cheryl Pistone

The AAAHC Institute for Quality Improvement has released its Quality Roadmap 2019 report that reviews more than 1,250 accreditation surveys from 2018 and identifies areas of high and low compliance. The report pinpoints trends ambulatory health care organizations should pay attention to when designing programs to improve their performance and quality of care.

In the 2019 report, the most common deficiencies centered on credentialing and privileging, quality improvement and infection control/safe injection practices. Across all of these areas, however, one issue continues to arise among the most common deficiencies – poor document management.

Importance of Documentation

Requirements for detailed and complete documentation appear throughout the AAAHC accreditation standards. For many standards, written documentation facilitates quality patient care and is the surveyor’s primary source of confirmation that the requirement is being met.

Often, an organization has a process to meet the requirement, but does not include the follow-through via written documentation to fully satisfy the standard. Documentation is vital to ensuring patient safety, quality of care and consistency, helping teams identify errors early and make the necessary adjustments.

In addition, proper documentation assists in negotiations with payers or liability insurers, while providing essential back-up in the event an organization becomes involved in litigation.

Tips for Documentation Best Practices

Across all categories, AAAHC surveyors recommend organizations determine one consistent method for documenting information, and incorporate that step into all policies, procedures and staff training. In the Quality Roadmap 2019, document management deficiencies were highlighted in four key areas, accompanied by expert insights on how best to avoid citations and develop long-term best practices:

Medication Reconciliation

Common Citations:

  • Incomplete documentation
  • No newly prescribed medications listed
  • No form provided to patient at discharge


  • Verify and document medications before and after each patient exam or procedure
  • Implement a “single-source” document policy for tracking the patient’s current and past medications
  • Deploy ongoing staff training on the necessary steps associated with medication reconciliation and how best to document all the information

Emergency Drills

Common Citations:

  • No documentation for number of drills conducted
  • Drills not regularly evaluated or missing evaluation documentation
  • Missing template form/checklist of all required drill information


  • Have an impartial party view drills while they are being performed and conduct a written evaluation
  • Create a practice drill checklist and timeline to ensure all appropriate steps are taken and documented

Patient Allergies

Common Citations:

  • Allergies, sensitivities and reactions not consistently updated at every visit
  • Allergies documented but no specific reaction information recorded
  • Inconsistent allergic reaction documentation


  • Have a specific place to record the allergic reaction next to the list of allergies for clarity
  • Train staff on all allergy documentation requirements, with regular refreshers throughout the year

Clinical Records

Common Citations:

  • Incomplete or missing health and physical forms
  • Paperwork not consistently signed off by ordering physician or qualified designee
  • Missing discharge summaries


  • Conduct chart audits to ensure complete clinical record documentation
  • When clinical records are incomplete, consider developing a quality improvement (QI) study to improve processes and performance

While documentation may seem tedious or redundant at times, deploying an effective management system can have a significant impact on patient safety and outcomes.

AAAHC’s Quality Roadmap 2019 report is designed to help organizations understand the AAAHC standards and provide useful benchmarks to aid in quality improvement. The annual Quality Roadmap works hand-in-hand with AAAHC’s growing portfolio of educational programs and quality improvement resources designed to enhance operational efficiency and performance, not just on the day of the survey, but throughout the 1,095 days of an accreditation term.

To learn more about the top deficiencies cited in the AAAHC Quality Roadmap 2019, please down the report here.


About the Authors

  • Naomi Kuznets, D., AAAHC institute vice president and senior director at AAAHC Institute for Quality Improvement where she currently oversees development and implementation of ambulatory healthcare performance measures and benchmarking.
  • Belle Lerner, MA, AAAHC Institute assistant director, is lead author for the 2019 Quality Roadmap.
  • Cheryl Pistone, RN, AAAHC accreditation services clinical director, served as an expert reviewer.




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