Clinical Documentation Matters

Physicians in the CAMP Method training study reported that their most significant documentation concern, prior to training, was their ability to clearly document the clinical significance of abnormal test results.  Since Joint Commission and Medicare both require documentation of the clinical significance of abnormal test results, training your physicians using examples of abnormal test results with several different suggestions for documenting the clinical significance of the test [depending, of course, on the individual patient]  is a key area for initial, follow-up or refresher training for your medical staff.

There are 1.2 billion outpatient and physician office visits per year in the U.S.  Research shows that between 10 and 70 percent of patient medical records contain documentation that is of poor quality, or on average about 45 percent.  Therefore, each year, about 500 million patient record entries are created that contain poor quality clinical documentation.