Why is clinical documentation important

The clinical and coding expert reviewers identified incomplete, missing and conflicting documentation that affected the CMG and weighted cases. One of the first set of queries involved any charts from April to December with unspecified pneumonia as the most responsible diagnosis MRDx. The process involved a standardized query for pneumonia, with an area for the CDI specialist to record supporting clinical indicators and a place to clarify the type of pneumonia specified.

This printed query form was placed in the physical patient record and kept in the incomplete chart area for the physician to review. After the physician completed the form, specifying the type of pneumonia required for coding, the form was added to the chart as a part of the legal medical record.

The impact was significant: the improvement in documentation specificity increased the RIW and expected length of stay ELOS in 76 cases of pneumonia. The overall impact on weight and length of stay for 76 cases of unspecified pneumonia was adjusted. The results are as follows:. A negligible number of pneumonia queries have been required since that time. Currently, physicians document as per standards learned through the query process.

Recognizing the value of comprehensive medical records, NHS held in-person training sessions and developed a physician education video for new onboarding physicians as well as education for the current physician population.

Clinical documentation is key in providing the platform for funding. The next steps can then be initiated to ensure proper education, engagement and process.

Ultimately, the goal is improved healthcare. Kim is a Clinical Nursing Specialist with a background in medicine, neurology ICU, community and intensive care nursing from various hospitals in Canada. With extensive medical and community knowledge as well as project management experience, Kim joined 3M to integrate clinical nursing into the Clinical Documentation Improvement CDI platform.

Kim is very passionate about improving clinical documentation to accurately reflect the quality of care that hospitals provide and to develop best standards for improving patient safety and outcomes.

Glad to see this article on how clinical documentation is related to improving patient care. As a physician I am very aware of the problems related to poor documentation. There is increasing literature on physician burnout and suicide. Surveys have shown that a significant contributor to these problems are the computer systems that we have to contend with.

Rather than trying to fix the person I think that it would be so much more effective to change the system. It is really disheartening to see how prevalent poor design is with the systems we have to use and how much effort it takes to get even little things get improved. Note: Please enter a display name. CDI and the Healthcare Continuum Patients flow through numerous care settings within the vast healthcare matrix, including inpatient and outpatient areas.

These characteristics include documentation that is: 2 Clear Consistent Complete Reliable Legible Precise Timely These characteristics can be applied across all healthcare settings. Inpatient hospital care. Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practice.

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Popular Posts. Patient Access: Continuing the Path to Compliance. White Papers. Sign up. Already have an account? Log in. Don't have an account? Click here to Sign up. Peer-to-peer support of documentation will increase standardization and productivity. Clinicians never stop learning as they practice and that should be true when it comes to documentation as well.

Regular emails with tips and ideas for improvement helps keep clinicians up to date on best practices and increase documentation compliance. Clear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient's treatment and maintain the continuum of care.

Take Dr. Schillinger's advice and "put thoughts to paper. With increasing rates of clinician burnout and increased demand at hospitals across the country, hospitals and health systems have had to get creative to provide quality Hospitals that employ their own EM and HM physicians face formidable challenges: clinician recruitment and retention, clinical leadership development and Filter Categories.

Select a year Business of Healthcare. Communicates with other health care personnel Documentation communicates the what, why, and how of clinical care delivered to patients. Reduces risk management exposure Thorough and accurate documentation mitigates risks and reduces the chance of a successful malpractice claim.

Ensures appropriate reimbursement A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any "hassles" associated with claims processing, and ensure appropriate reimbursement.