Clinical Documentation Matters

Clinical documentation embodies a good portion of the intellectual capital of your organization.  Today, we focus on ensuring high quality clinical documentation (HQCD) for patient care, reimbursement, research, and planning purposes.  These will always be important concerns.  However, as we enter the electronic medical record (EMR) era, clinical documentation takes on a new perspective. Now, we can design systems and use information to help protect the intellectual capital of the healthcare organization. The single most valuable tenet that an executive team in healthcare should remember is the following.  The knowledge worker is a key competitive differentiator for your organization.  It is your responsibility to capture as much of the knowledge worker’s intellectual capital through technology as you can for re-use by your organization as a whole. However, you still need to focus on the basics of strategy to win and keep patients.  Brook Manville and Nathaniel Foote identified the five basics of strategy that every organization must continue to focus on, even though you recognize the importance of knowledge workers and intellectual capital to your organization.  These strategy rules are outlined below.¹

If you have trained your physicians and staff members appropriately and implemented your program in accordance with solid training guidelines like those presented in the Compelling Case for Clinical Documentation books, the clinical documentation specialist’s (CDS) interaction with physicians should not be a compliance risk.  There has been some concern that certain CDS practices such as leading queries or inquiries written on sticky notes, or the physician’s interpretation of the question being asked of her is a compliance risk. Scenarios with the CDS asking the physician if a patient has blood loss anemia, a leading query, are anecdotal examples of potential compliance risks in the interaction between the CDS and the physician. It is unclear whether these scenarios have actually ever occurred, or if they are just worst fears expressed in the form of possible problems.  If your organization has implemented initial and continuous physician training, these compliance concerns should never become a reality for you.