Five reasons why clinical documentation matters (and how to improve it)
During a typical office visit, physicians gather important clinical information, make critical observations, and leverage problem solving skills to help patients feel their best. However, the specific details of each encounter may fade quickly from a physician’s memory as they move through a jam-packed schedule. It’s the written (or typed) record—the clinical documentation—that withstands the test of time and reveals each patient’s clinical story in a way that can be retold to others, including payers, other providers, and patients themselves.
The importance of good documentation in healthcare
Clinical documentation is just as important as taking a patient’s vital signs, collecting their medical history, examining them, and creating a treatment plan. Why? Because clinical documentation:
Builds patient engagement and trust. Nobody wants to divulge personal information to their provider only to then log onto the patient portal and read lackluster or inaccurate clinical documentation. As patients continue to access their own health information, clinical documentation is increasingly a reflection of how well their provider listens, understands, and respects them. The absence of good documentation in healthcare can make or break patient engagement and the physician-patient relationship.
Enables smooth transitions of care. Providers to whom patients are transferred must come up to speed quickly on each clinical case, and clinical documentation in the EHR makes this possible. Without good documentation in healthcare, providers must essentially start from square one. This inefficiency can cause treatment delays, jeopardize patient safety, and even produce negative outcomes.
Ensures revenue integrity. As far as payers are concerned, if it’s not documented, it didn’t happen. Payers want to know exactly what happened and why—with as much specificity as possible—sometimes before they even pay a claim. Or they may want to look at clinical documentation after payment to make sure the payment was justified.
Promotes high-quality patient care. Following clinical documentation improvement best practices helps ensure patients receive the right care at the right time.
Protects against lawsuits. Good clinical documentation helps providers avoid liability because it clearly and concisely justifies items and/or services billed.
Focusing on clinical documentation improvement
How can medical practices focus on clinical documentation improvement? Consider the following clinical documentation improvement best practices:
1. Leverage medical coders. Medical coders often have significant insight into payer clinical documentation requirements and clinical documentation standards. Therefore, they can educate clinicians on how to document appropriately. In addition, medical coders frequently monitor denials and can help identify proactive strategies to improve clinical documentation. For example, they may identify the need for greater diagnostic specificity, laterality, or a whole host of other details. They can develop a clinical documentation cheat sheet and compile various documentation tips for physicians.
2. Give patients access to their own medical records. Even despite a physician’s best intentions and efforts, it’s impossible to avoid clinical documentation errors and omissions 100% of the time. Having a second set of eyes—those of the patient—can help. By allowing patients to view their records via online portals, medical practices may be able to improve clinical documentation and enhance patient safety.
3. Review information. Taking a few minutes to review past clinical documentation and validate current notes with patients can be a game changer in terms of enhancing the quality and accuracy of clinical documentation. It usually only takes a minute to do this, and the benefits far outweigh any potential time lost during the visit. Figuring out how to improve medical documentation may be as simple as a quick final check.
4. Remember: Less is more. Good documentation in healthcare doesn’t necessarily equate to more documentation. In fact, just the opposite is usually true. Good clinical documentation is precise, timely, and clear. For example, it should not include information copiously copied and pasted from previous notes when those notes have no bearing on the present case. When in doubt, develop a documentation cheat sheet for common diagnoses and procedures to ensure the medical practice complies with all clinical documentation standards.
5. Leverage the EHR to reduce physician burnout. For example, take advantage of specialty templates or lab results right in the patient’s chart for easier reference.
Conclusion
There’s no doubt: Investing time and resources into clinical documentation improvement is an investment in the business. That’s because good clinical documentation helps medical practices capture and retain revenue. It also helps practices retain patients, and it demonstrates the high-quality patient care that physicians provide. Not sure how to improve medical documentation? Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
