Comprehensive clinical documentation done right

Riddle me this: "If a tree falls in a forest and no one is around to hear it, does it make a sound?"

Riddle me that: “If a clinician provides exemplary care to a patient but doesn’t document it properly, is it considered quality care?” While the latter isn’t a riddle, health systems and care providers have focused less on optimizing electronic documentation practices. An effort to provide exemplary care is likely to go unnoticed under emerging regulatory and value-based care models if it isn’t documented appropriately. As providers are increasingly being reimbursed based on the quality of care delivered – as opposed to merely the quantity of care provided – accurate documentation is more important than ever before. Therefore, provider organizations need to lay the groundwork for optimal documentation sooner rather than later.

Clinical information collected as part of the electronic health record (EHR) is becoming a critical component of documentation as organizations seek to improve the health of patients and populations under these emerging models. Clinicians are being called upon to meticulously document that high quality care services are, in fact, being delivered. Such documentation can, in turn, feed the constantly evolving knowledge base of best practices.

Factoring for comprehensive clinical documentation: Healthcare provider organizations need to look at current clinical documentation practices, identify gaps and make the changes that will lead to enhanced quality and subsequently improved reimbursement. To get started, here are 10 important factors that provider organizations should consider as they strive to create the comprehensive clinical documentation programs that will lead to success under value-based care:

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clinical documentation, clinical documentation improvement, EHR, electronic health record, Jacobus Consulting


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