Clinical documentation comprises all the information relating to each patient’s encounters with a healthcare facility. This information is entered in the medical record by a member of the patient’s healthcare team – a physician, nurse, therapist, dentist or other healthcare professional. Chronologically documenting this information in the medical record is essential for the provision of continuous, high quality care. With the rising incidence of patients with chronic conditions and complexities of EHR data entry, many practitioners consider medical transcription outsourcing as a reliable strategy to create proper medical records. Today, there is an increased focus on clinical documentation improvement (CDI) to ensure accurate, quality, complete, and specific documentation that reflects severity of illness and care provided.
Purposes of Clinical Documentation
The medical record is the most important means of communication between members of the patient’s healthcare team. As the American Health Information Management Association (AHIMA) explains, “Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient’s disease burden and scope of services provided”.
Good clinical documentation is important for many reasons:
- Promotes continuity of care and communication among healthcare professionals involved in the patient’s care
- Shows that proper care was given and documents the patient’s response to that care
- Provides evidence for legal records
- Creates patient registry functions to manage large populations better
- Provides information for researchers conducting scientific studies
- Helps create longitudinal patient records (LEPRs)
- Enables medical coders to prepare and evaluate insurance claims
Paper or electronic documentation needs to be supported by imaging records such as X-rays, magnetic resonance imaging (MRIs) scans, electrocardiograms (EKGs), etc.
Strategies to Improve Clinical Documentation
The AAPC defines CDI as “the process of reviewing medical record documentation for completeness and accuracy”. Clinical documentation review is performed by clinical documentation specialists who have both clinical and medical coding backgrounds. Here are some expert recommendations to improve clinical documentation:
- Plan ahead and hire efficient CDI specialists.
- Assess existing policies and procedures, including the current state of the facility’s CDI program.
- Educate clinical documentation specialists, coders, and other clinical professionals before setting up the CDI program.
- Review a sample of records to know where to focus efforts for documentation improvement and show how this will benefit the patient, practice, or population.
- Review the medical record before the encounter to assess for issues and identify compliance opportunities
- Have the CDI specialist review claims with targeted diagnosis codes before submission and determine if the documentation supports the codes. If not, the coder can reassign the codes.
- Consider the changing health care operational environment and prepare for it.
- CDI specialists should help physicians and coders work together to improve documentation.
- Utilize technology.
Benefits of CDI
CDI is beneficial for many reasons:
- More meaningful patient information: An effective CDI program results in a more useful medical record and more meaningful patient information and data.
- Improved patient care: Proper records can improve patient care in a healthcare facility. Review of documentation by the CDI specialist enhances communication between all providers involved in the patient’s care in a timely manner. This can reduce the length of stay for the patient and also help prevent avoidable readmissions.
- Improved reimbursement: Payers often require additional documentation to support additional or more specific ICD codes to enhance hospital reimbursement and data collection. A CDI specialist can confirm patients have accurate diagnoses in the medical record by reviewing documentation and ensure comprehensive data for accurate reimbursement.
- Timely reimbursements: When there are no errors in the documentation, it can prevent delays in claims processing.
- Reduced denials: Improved clinical documentation can result in more accurate medical coding, which will reduce denials and improve the appeals process.
- Validation of care quality: By ensuring quality clinical documentation and data, CDI can help health care professionals meet the demands to provide evidence of the quality of care.
- Capture of accurate risk adjustment scores: Continuous capture of all chronic conditions on a yearly basis, accurate HCC coding, and identifying risk adjustment scores can lead to better patient treatments and outcomes as well as proper Medicare physician reimbursement.
- Promotes compliance: Poor documentation lead to errors in claim submissions which can attract audits, and results in fines or return of money mistakenly collected from payers. When documentation is accurate and complete, it supports consistent compliance with regulations.
When successfully implemented, a clinical documentation improvement program can ensure accurate and thorough medical record documentation. This will improve reporting quality, promote accurate reimbursements, and drive better patient outcomes. The widespread adoption of EHRs and technologies such as front-end speech recognition has made it easier to create clinical documentation. Partnering with a medical transcription company can help providers alleviate much of the burden associated with EHR data entry and ensure accurate documentation of medical history, physical exams, medication lists, and more.
