Clinical documentation to improve patient care is a challenge for most healthcare professionals. As doctors and nurses learn that the lack of good clinical documentation results in poor reimbursement, wasted time, and bad patient care, the demand for a tool to improve their documentation rose.

Improving patient care is what we strive for in the healthcare realm. Hence, it’s no denying that improving patient safety and quality of care requires adopting some patient-centered strategies, and clinical documentation is one of these.

Clinical documentation to improve patient care

We previously discussed how does an EMR improves patient care, and today we will focus on clinical documentation to improve patient care. But first, what is clinical documentation and why is it important?

Clinical documentation is the foundation of a patient’s medical record. It captures patient care from admission to discharge. Including diagnoses, treatment, and resources used during their care.

When documentation is complete, precise, and correct, uncertainty is avoided. Additionally, the communication between healthcare professionals improves.

Whereas incomplete or incorrect documentation, on the other hand, can have a negative impact on the quality of patients’ treatment. Which results in medication mistakes, longer lengths of stay, and improper (or no) post-discharge patient follow-up. As well as greater readmission rates, and increased care costs.

The importance of clinical documentation for health systems

Before we jump into clinical documentation to improve patient care and how real-time data can improve patient carewe need to showcase the importance of clinical documentation for health systems.

 Mainly, hospitals and health systems trying to survive and thrive under value-based reimbursement recognize that good clinical documentation is key to ensuring quality care and optimizing revenue cycle management. 

On the same note, clinical documentation improvement specialists are trained to have a firm grasp of the clinical details of high-quality care and to be able to spot gaps in electronic health record charting. Consequently, natural language processing and machine learning can help in big ways, but good CDI also definitely depends on good person-to-person communication and collaboration.

Why is clinical documentation improvement important?

 Care to know why is clinical documentation to improve patient care very important? Well, clinical documentation, or CDI, simply aids in “ensuring that the events of the patient contact are appropriately documented”. Additionally, the electronic health record properly represents the services that were rendered.

 So, it basically ensures that all members of a patient’s care team have the information necessary to properly treat the patient.

 How does patient documentation contribute to quality improvement?

 It documents patient care from admission through discharge, including diagnosis, treatment, and resources spent. When documentation is thorough, precise, and correct, uncertainty is avoided, and communication between healthcare professionals improves.

 Clinical Impact of CDI

Undoubtedly, more and more hospitals are getting better at CDI, but there are still plenty of tips and tricks for doing it better. There are seven characteristics that should be seen within clinical documentation for it to be recognized as high quality.

  •       Clear.
  •       Consistent
  •       Legible
  •       Complete
  •       Reliable
  •       Precise
  •       Timely

 What are the five characteristics of good medical documentation?

  •     Accuracy of the medical record: It should reflect the data provided by the actual source. 
  •     Accessibility of the medical record: Accessibility relates to the ease of retrieving data, and can be affected by several things.  The way the medical records are organized and printed makes a huge difference
  •      The comprehensiveness of data: All required data components should be captured in the record, and implies that the chart is complete.  Missing pages or records slow the progress of the review.
  •     Consistency of information in the medical record: The consistency of a medical record refers to the fact that the data are reliable and that the integrity of data has not been corrupted regardless of how often or in what way the data have been retrieved, viewed, stored, or processed. 
  •     Timeliness of information: The timing of documenting the data is a key component of data. Healthcare records should reflect current information that is documented as close to real-time as possible. 

 The challenge of translating clinical documentation into coded data

Naturally, once a patient is discharged, that patient’s medical record is sent to the health records department to be processed and coded. In order to produce a record of the patient’s medical journey, the coder evaluates the available data and translates diagnosis, procedures, and therapy into the appropriate International Classification of Diseases (ICD) codes.

This coded and abstracted data is the foundation for managing and delivering appropriate healthcare services. The data is used for patient quality and outcome metrics. However, sometimes, converting medical documentation and clinical terminology into the correct codes from a long list of options can be challenging. And it is even more difficult when the medical documentation is not clear, specific, or accurate, often due to missing or incomplete information.

Long story short

Finally, a clinical documentation program will focus on patient care quality and quality. As well as on outcome measurements, statistics, and research. The first step in defining the need for clinical documentation improvement is to understand the gaps in documentation and coding. Ideally, the next steps can then be initiated to ensure proper education, engagement, and process. Ultimately, the goal is improved healthcare.

To learn more about this subject, you can call the Ambula Healthcare team: at (818) 308-4108. And now do you know why is patient engagement important?

Published On: April 12th, 2022 / Categories: Healthcare EMR Software /

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