FAQ’s About Clinical Documentation

FAQ’s About Clinical Documentation

Good documentation is required in any field, more so when you are dealing with patients. Clinical documentation is the documenting of patient’s record of diagnosis, treatment and post care. Maintaining effective documentation of each patient would help access data as well as give the right and appropriate care to patients. A good improvement program would solve the need for effective documentation. There are many questions asked about documentation improvement programs. Some of those frequently asked questions are answered here.
•What is the difference between clinical documentation improvement program and other programs?Clinical documentation helps the hospital staff in two ways. Firstly, it is a systematic procedure of recording the medical aspects of a disease, treatment provided and other procedures performed to ascertain accurate condition, treatment and follow up of the patient’s condition. This not only serves as a patient’s record but is also helpful for the accurate billing of all the services rendered by the hospital.
•What elements are involved in clinical documentation improvement program?The biggest challenge that the medical staff face is the lack of clarity in the records regarding the disease or its diagnosis. This results in inability to assign codes to the documents. Through ch a program, the type of queries that a physician asks frequently would be documented and coded. This is primarily to track the severity of illness and to record the risks involved in the mortality score of the public.
•How can the gap between the documentation staff and coding staff be bridged? Training of both the documentation and coding staff together would be the first step taken by the clinical documentation improvement program. Engaging both the documentation team and the coding team in discussions would help bring better understanding between the teams about the complexity of work involved. This would also help improve the understanding between these teams and the physicians and improve their documentation procedure. The clinical documentation improvement program would reflect the clarity of the physician’s implied thoughts in the clearly documented medical records.
•Regarding using the clinical documentation improvement program, how often and how much would a person in the team be involved?
In order to put in place an effective and efficient documentation improvement program, after the initial training, the teams need to be an essential part of the entire improvement plan, participating in every aspect of the program. The coders, documentation specialists and the physicians need to speak and hear the same language and message. The documentation specialists and the coding team need to be involved in all trainings that are educational. Efforts should be made to exchange inputs between each other in order to see measured improvement in the program.

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