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Clinical documentation is the nucleus of every patient encounter. It Provides a record of the conditions being treated and the care provided by providing communication tool between caregivers. In order to be meaningful it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into Accurate code application (ICD-10, CPT,HCPCS,DRG),Accurate Coded data is then translated into quality reporting & Standardized medical data, which Allows World Health Organization, Centers for Disease Control, etc.. To trend and track health issues. The Clinical documentation is also Increasingly used in hospital/physician profiling to determine future managed care contracts.
Most importantly Successful clinical documentation improvement (CDI) programs Improve Quality of care by correctly capturing the patient severity of illness (SOI),Risk of mortality (ROM) and Average length of stays (ALOS) , so that the Hospitals can report the appropriate level of care also improve case mix index (CMI) for the hospitals, and improves reimbursements for the hospitals.
The merging of clinical, documentation, and coding processes is crucial to a healthy revenue cycle, and importantly, to a healthy patient. To that end, CDI has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date.
A CDI program is a team approach, where people ,processes, and technology must work in alliance to ensure success. Organizations need a well-versed individual who can effectively articulate all the pieces: documentation requirements, code assignment, coding guidelines, and quality reporting.
The Physicians and Allied Health Professionals are the Key stakeholders when it comes to Accurate and precise Clinical documentation. Nurses have a strong clinical background which helps them identify gaps in the clinical evidence and documentation.
The physicians are the head of multidisciplinary unit responsible for the patient quality of care, the clinical Documentation is a reflection of the care being provided. Physician must document the more specific, precise and detailed documentation to captured the accurate details for improving the Quality care. The golden rule for the Clinical documentation is, If is not documented, “it” never happened”, “Be Specific & clear in the diagnostic/Procedural Terms ” and “Document all conditions / diagnoses /Procedures.
The physician Documentation must reflect the severity of illness through the selection of Principal diagnosis, Secondary diagnoses and procedures performed. If documentation/coding is incomplete, non-specific or inaccurate; Severity of illness will be impacted.
Some physicians Document in CLINICAL terms ((Documentation needs clarification) However, for coding, profiling & compliance requires specificity in DIAGNOSIS terms ((Accurate code may be assigned), No one has the right to change or interpret the physician’s judgement on the Diagnosis or the treatment given, However, CDI specialists may query for increased specificity regarding type of condition, degree or severity of condition, complications, combination codes, laterality, acuity, external causes, intent of procedure, the clinical significance of abnormal lab values / investigations and more. Physician engagement and responsiveness to queries will assist in capturing the most accurate picture of the patient’s severity of illness and risk of mortality (A diagnosis will not be reported based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record)
Ideally the Medical records should always reflect the seven pillars of high quality clinical documentation:
Modern health care is a team venture. And more often than not, the first person a patient meets in any setting or type of care is a highly skilled allied health professional. These are the therapists, scientists, technologists, administrators, managers, and assistants who comprise the backbone of our health care workforce. Their role in providing optimal patient care and satisfaction is critical, indispensable, and distinct from medical, nursing, and dental professionals.
Allied health professionals support diagnosis, recovery, and quality of life. They provide direct patient care in virtually every specialty; deliver scientific support in clinical laboratories; offer numerous rehabilitation services; manage and provide data critical to seamless patient care and diagnosis; operate sophisticated diagnostic equipment; contribute to broader public health outcomes; provide critical care support in intensive care units; develop hospital and educational nutrition programs; illustrate medical textbooks; and more.