Clinical Documentation Matters

No matter how you slice it, clinical documentation improvement is about change.  And, my research has shown that physicians involved in a new CDI program are most concerned about whether they will have "enough time to document properly."  Ironically, after the training sessions we conducted with physicians in our studies, 78 percent felt as though they were actually able to document more efficiently because they felt more confident about what they were documenting.  None the less, time management is an issue for physicians. Period.  Therefore one of the resources we've compiled is a Time Management Guide for Physicians.  While the guide is useful for CDI programs, physicians can benefit from the content at anytime.  We pulled research together that looked at what worked best for physicians as well as non-physicians and melded it into a simple 30-page document that you can share with your medical staff.   The other resource Change Management for Clinical Documentation describes the 8 essential activities for successful change management and can be used in either initial implementation of a CDI program or to improve an existing one.  Will be writing more about these two resources and Time and Change management in the weeks to come.  In the meantime, enjoy!