What is clinical documentation?

A clinical documentation improvement program involves a huge amount of paper works as the record of every possible details are to be kept which includes the details of the care given to patients, details of all treatments, medication and the even the lawsuits, if any. The general checklist of the documentation will include a wide range of forms, records keeping guidelines and a lot more. To start with, the very basics of the process of documentation will include the name of the patient, age, sex, date of birth, address and the emergency contact details of the patient. In addition, it is very important for the document to have a unique patient identification number that should be present in all the pages of the clinical documentation.

Since health care is unique for each person, it is very important for the regulatory bodies and the organizations to standardize the comparison. Newer technologies are able to capture the data and translate the clinical documentation improvement program codes into the CPT and the ICD-9-CM that helps in the proper and easy maintenance of data. The new technology that has been introduced in the industry provides for the accurate collection of the data and thus avoids discrepancies.

The main purpose of the clinical documentation is communication and thus it must attest the correct details and in a systematic manner so that it can facilitate communication. With the new regulations coming in, the most important is the data collected and its acute representation of the health care services by the exact representation of the diagnosis and the treatments provided to the patient. The regulatory bodies see to the clinical documentation improvements and abiding the rules and staying in tune with checklist helps provide unique service to the patient that is the ultimate purpose.

The improvement of the accuracy of the total process of clinical documentation improvement program is very important as it reduced the risk of complication in treatment and thus provides better care. These also reduce the risks of any problems during external audits and the legal matters related to health care. These policies also requires a certain amount of transparency in the policies followed for maintaining, enhancing and establishing the documentation and thus catering the unique needs of health care.

The other important checklist of the process of clinical documentation improvement program includes providing legible documents which at the same time should be accurate, precise, consistent and clear and should provide the medical histories, decisions, treatment provided, medical test reports and the outcome and the patient’s response to the treatment. In short, the documentation should be informative and provide actual information with the mentions of the levels of severity, expected risk of mortality with the complexity of the care provided and all the data collected should be kept private under all circumstances.

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