Clinical Documentation Improvement: A Comprehensive Guide

The Importance of Clinical Documentation Improvement

1  To every patient in a hospital or clinic, documentation is the most important thing. The documentation must be done precisely and carefully for it to make some meaning.it must be done at the appropriate time, accurately and reflect on all the details of all the services provided .a good clinical documentation improvement program should pay attention to facilitating accurate and detailed clinical state of the patient in form of a coded data (Balog, Narasimhan, & Shore, 2018).

The convergence of the documentation and the process of coding are essential to the revenue cycle of healthy and also to the patient. Clinical documentation improvement, therefore, has immediate effects or impact on the health care of the patient. It provides the patient’s information to all the health care team members and even to those who may be required to offer treatment to the patient in future.

The program involves a good number of processes and people who are obligated to work in unity for the program to be a success. All the people working in a clinic or as the health care personnel must be well –rounded and flexible enough to effectively address the code assignment, documentation requirement as well as quality reporting.

The professionals who deal with a clinical documentation improvement program are mostly drawn from either the professional nurses or clinicians or health information management professionals. Through their education they are able to comply with the rules and regulations pertain documentation. Examples of the regulations have to do with the privacy confidentiality and security of the information (Towers, 2013).

1. Clinical documentation improvement (CDI) is an important tool in the healthcare system. The clinical documentation improvement is a key quality document that is very important to all healthcare staffs. It is used in recording the patients care and noting the recovery progress which is very crucial in improving the patients care. The clinical documentation improvement method is useful in the communication between the patient’s care providers and the chief medical staff. To ensure that all this is met, the clinical documentation improvement program is timely, clear, complete, legible and precise. Good clinical implementation program increases the recognition of observable conditions that are effective during diagnosis, treatment, safety and to show the validity of the care provided to the patient. The presence of good clinical data through clinical improvement documentation leads to increase in hospital revenue. Clinical documentation improvement helps in avoiding penalties from non- compliance and ensuring full reimbursement from payers and insures. This eases the work of the chief financial officer in the healthcare institution. Accurate clinical documentation improvement practice results in significant financial profit and operation efficiency of the healthcare organization. Clinical documentation improvement initiates the positive health outcomes through preservation of important opinions provided by several medical officers. The clinical documentation improvement entails all the services given to the patient previously and also directly on the next required services. This helps in decreasing mistakes and errors that occur from the patient’s caregivers (Dehghan, Dehghan, Sheikhrabori, Sadeghi, & Jalalian, 2013).
2. The consequences of failing to implement a clinical documentation improvement results to serious problems within the health center. The issues that may arise due to poor documentation leads to higher incidences of financial losses, low-quality patient care and different errors within the hospital operations. Hospitals without good health documentation projects have more cases of mortality rate. Lack of clinical documentation improvement program within the health center makes some of the service providers to drag their feet when it comes to implementing their duties. The health institution that does not use the clinical documentation improvement projects reports significant low workday services provided and also low-quality clinical records with erroneous information. This diminishes patient’s healthcare in the hospital. Lack of implementation of the clinical documentation improvement may result in negative impact when it comes to diagnosis, treatment and all other assessment care carried out to the patient. In the health institution that uses the Electronic health record (EHR) program are not all that accurate as their documentation process fails to rectify the documentation alerts, tweak template and vulnerable documentation. This is where these higher health institution front- back to clinical documentation improvement project in collaboration for efficient operating practices.
3. Refuse to engage false activities. The implementation of clinical documentation improvement act as a good guideline for the nurses and all other service providers to the patient. It helps one, to be honest, and enabling he or she to perform the duties in the best ethical standards possible. The service providers take their jobs as their responsibility and offer the services in the best way possible.

  Facilitating complete, accurate and consistence clinical documentation in the healthcare center to support coding and getting high-quality information. The clinical documentation improvement is used as one of the best methods of documentation that gives accurate, clear and consistent data of high quality. This makes it easier for the patient’s assessment by the chief medical officer and also to other caregivers (Devkaran & O’Farrell,2014). 

Protection of patient’s confidentiality. The clinical documentation improvement project contains guidelines that ensure that the patient’s personal details like the name, age or disease information are not exposed against the will of the patient.

Initiation of interdisciplinary collaboration. This is where a documentation like clinical documentation improvement program ensures that each and every service provider records the details about the patient that correlate with the previously recorded information of the other attendants. There is no interaction between any of the two consecutive service providers which could endanger the patient health.

Physician Roles in Clinical Documentation Improvement

Support of reporting the accurate and complete healthcare data elements. These help in the patient’s progress in recovery and best treatment as it is indicated in the clinical documentation improvement program.

Demonstrating the level of integrity and behavior. Through implementation and performing in accordance with the guidelines of the clinical implementation improvement strategy, a service provider is able to use the best of his or her skills practically to save the life of the patient (Jacobson, Thompson, Halvorson, & Zeitler, 2016).

Avoiding to participate in unethical reporting cases. The service provider who adheres to the rules and regulation of the clinical documentation improvement program ensures honesty and ethical health practices. Through this element, it is easier to notice the one with unethical report practices due to the frequent assessment of the patient by different profession who records a meaningful data that should be consistency. (Rains,2017).

Advancement of profession knowledge by a linear continuity of the education. The clinical documentation program gives one an opportunity to learn and get more updated information from other professional’s record by retrieving through the clinical documentation improvement program (Jafarzadeh, Thomas, Marschall, Fraser, Gill, & Warren, 2016).    

5 The physicians have a couple of roles that they must play to ensure the success of the clinical documentation improvement program. To begin with, they must develop and maintain a unique record for an individual patient who they encounter in the clinic. Physicians store and preserve all the medical information in a place that is secure and is accessed only by the authorized medical professionals. It is also the responsibility of the physicians to organize the medical records and documents in a neat and specific order to keep the offices clean and neat. (Pan, Shaitelman, Perkins, Schlembach, Woodward, & Smith, 2016).

The physicians are also obligated to come up with a well-organized system for record-keeping so that they can make sure that the medical records are legible, accurate and can be retrieved when needed for future use. They also keep the privacy and confidentiality of all the medical information regarding each patient (Breuer & Arquilla,2011).

6 Starting a clinical documentation improvement program is one of the hardest tasks that one can deal with in a hospital setting.in most cases, people are used to their own way of doing things and few are willing to change.in order to properly lead the clinical documentation improvement program, it is good to assess and determine how much support you are likely to get from the staff. By doing this, the HIM is able to formulate the best strategy to use in order to make a significant impact on the program. (Asakura, & Ordal, 2012).

Starting a Clinical Documentation Improvement Program

The HIM will start by seeking to understand some of the weaknesses and strength that likely benefit more from the CDIP. This will give the HIM a very good platform to begin. The assessment will be done to different services to suggest which service lines will be the first to benefit from the program (Ommaya et al 2018). The method will take a good note of the service or department with the poorest documentation habits which will be targeted. The program will begin paying greater attention to the services that desperately need improvement in the facility. All the clinicians will be taken through a series of training sessions. They may be done either one on one or during the staff meetings to prepare them for the anticipated changes. The training will be done in time to help people see the seriousness with which the program must be taken.

HIM professionals have many roles in ensuring any success of CDI program which affects the health care given to the patient. They must play their part in ensuring the implementation of the intended changes. They should help the chief medical officer supervise the overall compliance of the program by the staff’s members. (Ryan, Patena, Judd, & Niederpruem, 2013). They should also offer training to the staff and be flexible to offer their help any time it is required for the best results. 

References

Asakura, K., & Ordal, E. (2012). Is your clinical documentation improvement program compliant? Hospital finance executives, take note: your organization’s clinical documentation improvement program may soon be under a microscope. Healthcare Financial Management, 66(10), 96-101.

Balog, D. J., Narasimhan, M., & Shore, J. H. (2018). Clinical Documentation in the Era of Electronic Health Records and Information Technology. Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals, 227.

Breuer, S., & Arquilla, V. (2011). Clinical documentation improvement focus on quality: hospital clinical documentation improvement programs should move from a focus on payment to a focus on quality and outcomes. Healthcare Financial Management, 65(8), 84-89.

Dehghan, M., Dehghan, D., Sheikhrabori, A., Sadeghi, M., & Jalalian, M. (2013). Quality improvement in clinical documentation: does clinical governance work?. Journal of multidisciplinary healthcare, 6, 441.

Devkaran, S., & O’Farrell, P. N. (2014). The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis. BMJ open, 4(8), e005240.

Jacobson, T. M., Thompson, S. L., Halvorson, A. M., & Zeitler, K. (2016). Enhancing documentation of pressure ulcer prevention interventions: a quality improvement strategy to reduce pressure ulcers. Journal of nursing care quality, 31(3), 207-214.

Jafarzadeh, S. R., Thomas, B. S., Marschall, J., Fraser, V. J., Gill, J., & Warren, D. K. (2016). Quantifying the improvement in sepsis diagnosis, documentation, and coding: the marginal causal effect of year of hospitalization on sepsis diagnosis. Annals of epidemiology, 26(1), 66-70.

Pan, H. Y., Shaitelman, S. F., Perkins, G. H., Schlembach, P. J., Woodward, W. A., & Smith, B. D. (2016). Implementing a real-time electronic data capture system to improve clinical documentation in radiation oncology. Journal of the American College of Radiology, 13(4), 401-407.

Ommaya, A. K., Cipriano, P. F., David, B., Hoyt, M. D., Horvath, K. A., Paz, M. D., & DeFrancesco, M. S. (2018). Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout.

Rains, S. K. (2017). Clinical Documentation Improvement. Health Information Management: Principles and Organization for Health Information Services.

Ryan, J., Patena, K., Judd, W., & Niederpruem, M. (2013). Validating competence: a new credential for clinical documentation improvement practitioners. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 10(Spring)

Towers, A. L. (2013). Clinical documentation Improvement—a physician perspective: Insider tips for getting physician participation in CDI programs. Journal of AHIMA, 84(7), 34-4