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Technical Documentation inHealthcare DomainOctober 2014This document is confidential and contains proprietary information, including trade secrets of CitiusTech. Neither the document nor any of the informationcontained in it may be reproduced or disclosed to any unauthorized person under any circumstances without the express written permission of CitiusTech.
Agenda Overview Why Documentation in Healthcare What We Do How We Do It2
Overview of the TrainingThe objective of this presentation is to – Understand the importance of Technical Documentation inHealthcare domain Recognize and focus on key aspects of TechnicalDocumentation in the Healthcare domain Relate documentation with end user (patient or physician) inthe Healthcare domain Highlight the process used by us for Technical Documentation3
Agenda Overview Why Documentation in Healthcare What We Do How We Do It4
Why Documentation in HealthcareFrom EMRs and EHRs to medical imaging and e‐prescription,the sphere of digitalization has entered healthcare.Documentation is a critical piece in the jigsaw, if the Healthcaredigitization needs to succeed.5
Why Documentation in HealthcareTechnical documentation cansometimes be a very superficialprocess. For example, a writermay glance at an application, usethe application and document itin a flash.6
Why Documentation in HealthcareBut when it comes todocumenting aHealthcare application,Customer Focus not onlybecomes the key aspectbut it becomes a criticalaspect.7
Why Documentation in HealthcareA small error in documenting the usage of anElectronic Medical Record (EMR) application or asmall deviation in writing down specifications of aRadiology device could be potentially life‐threatening for patients who will be treated usingthe aforementioned devices.8
Why Documentation in HealthcareHealthcareDomainThe Healthcare domain is notonly one of the largestdomains but one where anenormous amount of moneyis being spent by variousGovernments across theworld.9
Why Documentation in HealthcareAs the whole world is moving towards digitalization, so is the healthcare field.Patient medical history is being stored in electronic format; the x‐rays andsonographies are being stored in applications where they can be shared acrossHealthcare entities, Meaningful measures have been incorporated to improvehealthcare.10
Why Documentation in HealthcareAll this and more has made itimperative for thedocumentation of Healthcareapplications and devices to betop notch if we are to improvethe quality of healthcare.11
Why Documentation in HealthcareDr. Smith’s OfficeI am suffering fromfeverA patient visits Dr. Smith’s office12
Why Documentation in HealthcareDoctor checks the patient andprescribes a medicine.13
Why Documentation in HealthcareThe Doctor or the Administrative staffDoctor tries to send the prescription tofind it time consuming to use the EMRa pharmacy using the EMR installed onbecause of lack of knowledge of EMRhis computer.usage.14
Why Documentation in HealthcareLack of effective documentationresults in more time spent onadministrative task for the doctor,which in turn results in less time spentwith patients.15
Agenda Overview Why Documentation in Healthcare What We Do How We Do It16
What We DoUser GuidesOnline HelpTraining ManualsSoftware Simulation (HelpVideos) Process Flow DiagramsInstallation GuidesContext‐sensitive HelpTroubleshooting GuidesQuick Reference Guides How to Documents DocumentationTemplates FAQs Release Notes Support Documentation Medical Dictionary On Screen Tips17
What We DoAs a technical writer in a Healthcare domain, one mustbe careful in what must be delivered to the client.A user guide must not be only a user guide but adocument containing the relevant healthcare workflowdetails along with the application information.18
What We DoThree areas of focus in healthcare documentation for usare ‐ No PHI in documentation Measure‐specific documentation Healthcare Workflow‐EMR Training Videos(Interactive and Non‐interactive)19
What We DoPHIThe Healthcare domain contains a very importantelement i.e. the PHI data. PHI stands for Patient HealthInformation.Special care has to be taken not to have any PHI data inthe documentation.There can be instances when images that we take ofhealthcare applications may contain PHI data, we needto be sure that this information is erased from images.20
What We DoMeasure‐specific DocumentationClinical quality measures, or CQMs, are tools that helpus measure and track the quality of healthcare servicesprovided by eligible professionals (EPs), eligiblehospitals (EHs) and critical access hospitals (CAHs)We create measure‐specific documentation forhealthcare applications as it helps the medicalprofessionals to quickly understand the applicationfunctionalities.21
What We DoHealthcare Workflow‐EMR Training Videos (Interactiveand Non‐interactive)We create workflow‐EMR training videos for themedical professionals. These videos are created forevery hospital workflow including when and how theinformation is entered in the application at each stage.22
Agenda Overview Why Documentation in Healthcare What We Do How We Do It23
How We Do ItDocumenting a Healthcare application requires you tofollow an altered Documentation Development LifeCycle.We like to call it as HDDLC where H stands forHealthcare.24
wDDLCDocumentationCheck for ningsWorkflowbased TOC
How We Do ItAll the phases of DDLC need to be altered whendocumenting in the Healthcare domain.The Analysis phaserequires you to undergospecific Healthcare relateddomain trainings tounderstand medicalterminologies used in theproduct.26
How We Do ItExtra care should be takenwhile identifying theaudience, as differenttypes of MedicalPractitioners may havedifferent levels ofunderstanding of theproduct.27
How We Do ItThe Development phaserequires astutecircumspection as highlysensitive patient healthinformation (PHI) may beavailable on theapplication, which needs tobe removed from thedocumentation.28
How We Do ItThe Review process, apart fromhaving the standard Peer and SMEreview also includes a veryimportant Medical ProfessionalDocumentation Testing process.The usage of the application istested with the help of thedocumentation created andchanges are made if required. Thisconcludes the HDDLC.29
How We Do ItAbove All – Patient FocusThe goal is to produce documentationimproving patient care.We do this by – Complete verification ofinformation from healthcareconsultants. Dual testing – Testers as well ashealthcare consultants performsdocumentation testing. No application updates released without documentation. Real‐time analysis of documentation and improvements.30
How We Do ItStandards31
As technology progresses, we have the opportunity tostreamline documentation to benefit patients – allowingproviders at every point of care to access health records sothat drugs do not negatively interact, tests are not repeated,symptoms are not overlooked.32
Technical documentation in a healthcare domain is a criticalwriting assignment, which requires impeccable accuracy andabidance to the healthcare domain standards.33
“A single mistake in end user documentation may have adangerous effect on the life of a patient.”As a writer our focus needs to be improving thedocumentation for healthcare applications therebyenhancing the quality of healthcare provided to patients.34
Thank You!35
The Healthcare domain contains a very important element i.e. the PHI data. PHI stands for Patient Health Information. Special care has to be taken not to have any PHI data in the documentation. There can be instances when images that we take of healthcare applications may contain PHI data, we need
