Because physician visits are responsible for 80 percent of all outpatient visits, the importance of high quality clinical documentation is clear, especially if your healthcare system employs or owns physician groups, the importance of high quality clinical documentation is clear.
Although most organizations begin a documentation initiative in the inpatient arena because of the complexity and amount of documentation, depending on how your organization is structured and your strategic approach to the program, you may actually begin your clinical documentation program across several different patient care settings. For example, if you are structured by product line, you may decide to focus first on the cardiology product line. This strategy would involve quality initiatives for documentation in the inpatient cardiac units, the cardiac catheterization laboratory, cardiac rehabilitation programs, and cardiology groups employed by the organization.
The initial investment in this process is much higher than rolling out a program by setting. However, once you have implemented across one product line, the ease of implementation across others increases. Although this strategy is not the most common, the ability to build strong physician alliances is greater than when implementing a program by patient setting.
Consider this list of patient care settings - each of which should have a clinical documentation quality program as part of its day-to-day operations and strategic planning processes:
• Acute care
• Sub-acute care
• Rehabilitation
• Skilled nursing facility
• Psychiatric hospital
• Physician office
• Clinic
• Same day surgery
• Outpatient rehabilitation center
• Emergency department
• Urgent care center
• Hospital outpatient department
• Radiology/MRI centers
• Diagnostic laboratory
