Clinical Documentation Improvement

Many physicians voice comparable complaints when they try to make a diagnosis, review procedures that the patient has undergone or prescribe proper medications. Such lapses can directly affect the quality of care that a patient receives, or how a healthcare organization is reimbursed for the services it delivers. Both scenarios highlight the importance of clinical documentation improvement, and why clinicians and coders need to embrace best practices around it. The lately implemented ICD-10 codes definitely add to the challenge, but the overall goals of increasing quality of care while reducing cost of delivery are driving new interest in the topic of clinical documentation. Clinical documentation improvement is quite hot right now.

It has been around for quite some time, but it’s really catching on with ICD-10 and the need for more specific documentation.”. The stakes are high. Clinical documentation is the critical piece behind health data informatics, or the use of clinical data to make decisions on individual patient care and population health management. Interestingly, it isn’t the greater health data coding demands of ICD-10 causing the greatest pain around clinical documentation improvement, Endicott said. Just the very move to the electronic healthcare record has made the entire process a burden. Coders and developers can, and should, go a considerable way toward simplifying the process.

I think the EHR has just become so complex. For a doctor to navigate throughout the EHR, there are numerous different screens that they’ve to go through. Lots of times, info is copied and pasted in different sections, so you are seeing a repetition of everything in multiple locations, and you are not sure what’s new or if it was from a previous visit. If you do not have other sources of data to supplement what they put in, you’ll have a pretty incomplete picture.”. Data professionals may have little luck to improve their analysis of patient and health data if they’re starting with an incomplete data set. The remedy for many healthcare organizations comes in the shape of a brand new hire: a data professional who can triage clinical data as it enters the pipeline.

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