Clinical Documentation Improvement

Clinical Documentation Improvement - Its Role & Importance

Accurate, timely and compliant clinical documentation is essential to the smooth running of modern healthcare organisations. As the demands and challenges posed by clinical documentation continue to grow, healthcare providers need to adapt, change and improve their processes, tools and training.

Healthcare faces a number of pressures in relation to clinical documents

Documents need to accurately present information for other care providers and organisation.
Clinical documents must be created and sent quickly to the next stage in the patient journey.
Requirements or regulatory obligations from local, national and international organisations for documents must be met.

But for all these challenges, clinical documentation represents an excellent opportunity for organisations to improve the efficiency and efficacy of their operations. Improving documentation reduces errors, increases financial claim successes and positively impacts actual patient care.

Many healthcare organisations are choosing to place improvements to documentation at the center of their wider efforts to improve as an organisation.


Defining Clinical Documentation Improvement

The Clinical Documentation Improvement exists to fulfill the growing need for healthcare providers to to comply with regulations. Improving documentation means better managing care profiles, improving accuracy of documents with respect to reimbursement needs and liability exposure.

CDI ties together the clinical team and the coding department to produce the most accurate and complete medical records possible.


How CDI Programs Work

A CDI program generally starts at a high level with planning around objectives and requirements. Priorities are set such as a target for improvements on reimbursement or compliance with a particular regulation.

Many care providers supplement their CDI programs with a Clinical Documentation Integrity Specialist. This specialist reviews medical records for incomplete, ambiguous or conflicting information. The CDIS’s role is to ensure that medical records accurately reflect the severity of the patient's condition and the full extent of the treatment. The specialist acts between the medical and coding teams and requires a sound clinical knowledge as well as critical thinking capability.

The recommendations of the CDIS can be taken into account and worked into the operations of day to day documentation. Training and behavioural change is not simple or quick but can be successful with persistence.

Software change is often included in a CDI program. When behavioural change and training is not enough to improve documentation practices it is necessary to look at the systems used. Doctors may not have the tools they need to be accurate and complete with documentation.

Winscribe’s Role In Clinical Documentation Improvement

Winscribe’s medical documentation, dictation and speech recognition software forms an important component of the Clinical Documentation Improvement process.

Clinicians can be supported in their documentation efforts by an intuitive software that allows them to document the detail and nuance of a patient's circumstances without the need for point and click interactions.

Moving the burden of documentation costs from clinicians means they are able to spend more time with patients and can devote their attention better to the patients they are with.

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