At The Crossroads Clinical Documentation & The EHR

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As healthcare reform transitions from volume-based reimbursement to value-based reimbursement, physicians and healthcare organizations must justify patient treatments and demonstrate quality outcomes. The key to accomplishing these objectives is through complete and accurate clinical documentation.

Confronting the mission to produce the highest data quality possible is a core challenge in clinical documentation. We clearly need structured, codified, and normalized data that can be accessed and analyzed. At the same time, there remains a strong demand for the context, detail, and reasoning that unstructured narrative documentation uniquely generates.

The core strategy for improving clinical documentation is by embracing the reality that different styles of documentation are best suited to different types of patient information. Some data is quickly and accurately captured in forms, fields, and templates – such as data entered via EHR templates. Whereas, some information is only viable through narrative patient analysis.

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