Clinical Documentation Matters

The Patient's Bill of Rights was passed during the Clinton Administration.  Although the bill only applies directly to Medicare patients, most hospitals have adopted their own - and post it throughout the hospital as well as on their website.  Two provisions in the bill relate directly to clinical documentation. They are:

1. The Right to Information. You have the right to receive accurate, easily understood information to assist you in making informed decisions about your health plans, facilities, and professionals.
   
2. The Right to Be a Full Partner in Healthcare Decisions. You have the right to fully participate in all decisions related to your healthcare. If you are unable to fully participate in treatment decisions, you have the right to have parents, or guardians represent you.  

If you aren't already, have you thought about including this information, along with your hospital's Patient's Bill of Rights Statement in both CDI training as well as CDI operations?  The right to information, for example, could be footnoted on all CDI reports or the CDI dashboard.  The Right to be a full partner in healthcare decisions is a bit more indirect - but certainly reviewing your medical record documentation and understanding it - could be viewed as part of that right.  What other rights has your hospital embraced in its own Patient's Bill of Rights that can be used in your CDI program? Read the complete Patient Bill of Rights to get a sense for the overall perspective.