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Comprehensive clinical documentation done right

Paulette Schroeder, Senior Managing Director of Clinical Informatics, Jacobus Consulting

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:

#1: Complete, comprehensive data is a non-negotiable imperative.Both coded, discrete data and “non-codable” narrative notes are important when documenting care in the value-based care environment. This combination of narrative and discrete clinical information helps to tell the complete patient “story” and provides organizations with the foundation needed to move toward enhanced care experiences, improved outcomes and reduced costs associated with the triple aim.

#2: The value of discrete data. Discrete data can help develop the metrics that are needed for clinical care quality improvement efforts both on the patient and population level. In addition, when electronic medical records include prompts that call for discrete data, clinicians are more likely to document the quality of care they deliver. For example, these fields might ask for – and then prod – clinicians to obtain and document information on glucose levels or provide immunizations. In addition, discrete data is the critical component for the standardization of data input and output throughout a health care information system (HCIS), allowing for the proper exchange of health information (i.e. with a health information exchange (HIE), regardless of underlying technologies), and enabling organizations to extract clinical information for utilization in Predictive Analytics and Business Intelligence.  As such, provider organizations should incorporate discrete data documentation into EHRs whenever appropriate.

#3: The importance of narrative data. Adding narrative clinical information into the mix makes it possible to develop the foundation needed to describe the state of the health of patients. Such descriptions can illustrate the improvement that patients are making towards optimal health. Laying this groundwork is becoming increasingly important under emerging value-based models. Currently, such documentation is most critical in the Medicare Advantage environment as there is a direct revenue consequence associated with the initiation of Hierarchical Clinical Categories (HCCs). These HCCs are designed to adequately reimburse clinicians for taking care of sicker and more complex individuals; to usurp the “cherry picking” of patients; and to ensure that those people who were more medically complex received the care that they needed from qualified care providers. Under this program, clinicians need to understand the key principles that drive HCC risk adjustment. The calculations are dependent upon accurate documentation leading to accurate coding, which places care into the appropriate clinical categories.

#4: The need to substantiate complexity. Under value-based care, reimbursement improves as the complexity of the patient increases. In essence, reimbursement is dependent upon the number and severity of conditions and comorbidities and the intricate relationships of these conditions.

Properly executed digital clinical documentation supports this risk adjustment and stratification. In essence, risk adjustments are dependent upon the utilization of specific codes. And, the codes are, in turn, dependent upon how clinicians enter the information into the medical record. Clinicians, therefore, need to understand the documentation “rules” so that a coder can translate accurate clinical documentation into ICD-10 coding that can then be applied to a risk adjustment model. Such collaboration between clinical care delivery and documentation staff members can help support the Patient Centric Revenue Cycle and enhance bottom line reimbursement. 

#5: Why it’s important to leverage templates for common diagnoses. Documenting discrete data can be more time consuming for physicians than dictating narrative notes. Organizational leaders should determine where it is most beneficial to collect discrete data via their EHRs based on unique Physician Specialty. Instead of creating templates for all of the Centers for Medicare and Medicaid Services’ 25 quality measures, medical practices need to create templates that collect the data that affects a significant portion of their patient population. By doing so, they can efficiently and cost effectively develop templates and train physicians, staff members and coders to collect the information that will have the most significant impact on quality and reimbursement at their practices. For example, if 25 percent of a medical practice’s patients are diabetics, then it would make sense to set up templates that collect discrete data related to diabetic care. This data, in turn, can be leveraged to monitor quality, receive optimal reimbursement and report outcomes.

#6: Why and when standardization can be a good thing. Frequently, clinicians balk at the standardization associated with collecting discrete data. It’s important, however, for caregivers to understand that standardization helps to improve quality and defend reimbursement, as it ensures comprehensive care delivery, accountability, and on-time payments. For instance, if a physician sees 10 patients with the same condition every day, the physician might actually forget to ask a question or to document an element of care, simply because they just did so with the previous patients. If templates call for such documentation, it is more likely that physicians will provide that documentation and qualify for the optimal and defensible reimbursement.

#7: The consequences associated with poor workflow. While clinical documentation is becoming more important under value based care, provider organizations need to ensure that documentation does not impede clinical workflow. According to “Electronic Health Record Use a Bitter Pill for Many Physicians,” a report published in Perspectives in Health Information Management, clinicians often find and use “workarounds” when the technology does not mesh with their needs. For instance, when systems are awkward to use, physicians will choose to underutilize the EHR during the patient encounter and instead complete required documentation sometime after treating the patient. In such situations, physicians often take notes on paper during the patient visit and then rely on this information to complete EHR data entry later. Such workarounds actually make EHRs less efficient – and add to physician workload.1 Organizations need to aim to develop templates and provide training that makes it possible to actually improve clinical workflow.

#8: The importance of right person, right time – right communication. It’s an absolute imperative to develop templates that enable the right clinical professional to document the right information. So, templates should be constructed with an eye toward accommodating  documentation from the appropriate clinicians – physician, nurse, therapist, etc. In addition, the templates should enable communication between the various caregivers, ensuring that the right information get to the right people at the right time.

#9: Why everyone needs to have their say. Involving physicians and other staff members in the development of documentation templates often helps to improve how quickly and adeptly clinicians adapt to the new documentation. Organizations need to include physicians and other staff members when building and optimizing the system. In addition, it’s important to look at workflow in terms of industry best practices and regulatory requirements. This prevents the organization from developing templates in a vacuum avoiding the potential for duplicative efforts.

#10: The dangers associated with data cloning. Medical groups need to specifically be careful about “whole- note cloning,” the practice of copying and pasting previous notes into the EMR in an effort to speed documentation. While this documentation technique can increase efficiency, it also can threaten the integrity of records. It is true that copying and pasting allows physicians to easily incorporate lab tests, vitals, and every conceivable report in a single progress note. However, the practice can result in inaccurate documentation as well. In fact, EMR cloning has resulted in Medicare and other insurance companies denying payments, thus inviting case review, delays in the revenue cycle, and new legal liabilities. Recent studies have also established EMR cloning as a potential factor in poor patient outcomes, such as when the cloning of glucose labs in hospitalized diabetics becomes harmful. As a result, medical practices need to make sure that they are always documenting care so that it reflects the particulars of the patient’s illness, with events sequenced chronologically, along with appropriately inserted clinical commentary and discussion of treatments.2

Considering these factors can boost healthcare organizations’ efforts to develop and implement the clinical documentation that will support improved care – and lead to both clinical and financial success under value-based care models. While the delivery and documentation of quality care accounts for 70 percent of reimbursement under value-based care, the other 30 percent emanates from patient satisfaction. Part two of this article series will focus on how provider organizations can develop the clinical documentation and communication programs that will result in much improved patient satisfaction.


  1. Meigs, S. Electronic Health Record Use a Bitter Pill for Many Physicians. Perspectives in Health Information Management, 2016 Winter. Accessed at:
  2. Cueva, J. EMR Cloning: A Bad Habit. Chicago Medical Society. Accessed at: