A solid foundation is important to any structure. Likewise, solid documentation serves as the clinical foundation for healthcare organizations. In a previous blog post, we discussed the importance of the “True Clinical Picture” and the instrumental role health information management (HIM) professionals play in data governance. In this post, we’ll focus on documentation and why comprehensive, accurate documentation is so important to all stakeholders in healthcare, from patients to providers, payers to researchers.

Compiling documentation is like putting together a puzzle – all the pieces should fit together to form a complete picture. It’s the job of HIM professionals to not only find all the pieces, but to assemble them to illustrate the full picture of a patient’s care. Medical records are the primary vehicle for communicating essential information about the patient’s diagnosis, treatment, and outcomes, as well as for communication between clinicians and payers.

The data in the medical record is the foundation of clinical documentation, which serves several important purposes:

  • For patients, it is the foundation for ensuring they receive proper care now and in the future.
  • Providers rely on the medical record for information exchange and to demonstrate quality of care.
  • Healthcare organizations and payers need medical records to support coding, reimbursement, quality initiatives, and denials management activities.

Improve Clinical Documentation Quality, Improve Healthcare

Think about a puzzle that is complete except for one or two missing pieces. While you can still get a sense for what the puzzle is depicting, you may not get the full picture because those missing pieces may include critical elements. The same is true with clinical documentation. Patient documentation is read by clinicians, providers, payers, legal entities, consumers, and other organizations with varying backgrounds, experience, and uses for the data in the records. A single missing piece may make a big difference in telling the story of the patient’s care to one or all these end users.

So how do we, as HIM professionals, ensure that all the pieces are in place? By ensuring the quality of the documentation within each patient record or, in other words, through Clinical Documentation Improvement (CDI). CDI is not new for the healthcare industry. Yet many organizations and providers continue to struggle with the essential elements of documentation.

Documentation within the patient record should be clear, concise, and convey the essential information that is required for treatment, payment, and operations.

Increasingly, CDI plays a significant role in quality, leading some organizations to take another look at their traditional CDI programs and shift to Clinical Documentation Quality Improvement (CDQI) programs to further solidify the content and messaging of patient documentation.

CDQI goes beyond simply audits and reviews to ensure the correct codes have been applied. It extends to finding opportunities to:

  • Improve specificity
  • Query physicians for clinical validation
  • Educate stakeholders on ways to improve the quality of the medical record, not just the quality of the coding

Organizations are also applying data analytics to identify problem areas by digging deeper into data points such as top Diagnosis Related Groups (DRGs), Case Mix Index (CMI), Major Complication/Comorbidity (MCC), and Complication/Comorbidity (CC) rates and linking data and answers to support a solid documentation foundation.

The Key to Building a Solid Foundation That Supports the True Clinical Picture

CDQI is all about complete, concise, and accurate documentation that provides holistic information regarding the care of the patient. The industry landscape continues to change with the call for greater transparency from providers, payers, and consumers. Organizations must review current documentation opportunities and take a proactive stance toward ensuring they are ready for changes that continue to impact their ability to provide top-notch patient care and to be appropriately reimbursed for that care.

Additionally, consumers are squarely in the driver’s seat when it comes to not only establishing a solid foundation but building upon that foundation for future care and overall health. Organizations must continuously strive to obtain and document data from consumers, family members, caregivers, providers, and clinicians involved in the care of the patient across the continuum.

It is critical for us as HIM professionals to ensure that clinicians and providers understand that their medical documentation matters because every record represents a real person and every record must present the TRUE CLINICAL PICTURE.

As HIM professionals, we are uniquely qualified to assist all contributors in the world of documentation. Regardless of the role or area of the industry we work in, documentation is the foundation for everything that we do, and it is our responsibility to advocate for complete, concise, and clear documentation. Every record and the data in that record must reflect care provided in the past so it can be effectively utilized for future care, diagnoses, treatment, and payment.

At the end of the day, everyone wins through quality – patients receive optimal care, healthcare providers benefit financially and operationally and ultimately, everyone realizes the benefits that come with the availability of high-quality health information. Focusing on improving the quality of documentation and medical records will allow you to consistently present the true clinical picture so your organization can make meaningful use of health information and achieve positive outcomes.

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