www.ClinicalDocumentationMatters.com Clinical Documentation and the Eight Phases of Electronic Medical Record Transformation
Today, most healthcare organizations are in some phase of evaluating, implementing, or upgrading information technology that is related to patient records. Whether it is computerized patient order entry, optical disc imaging, or implementation of a complete electronic medical record, these activities all present opportunities to improve clinical documentation.
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Order Now HIMANYC Sponsors CAMP™ Method Training, Trend Identified
On February 13, 2009 in New York City, over 60 HIM and clinical documentation professionals attended the CAMP™ Method training program sponsored by the health information management association of New York City (HIMANYC). A common concern for many attendees was training voluntary attending physicians or, physicians who are not employed by a healthcare system or hospital. Voluntary attending physicians, especially at small to midsize community hospitals, account for the large majority of inpatient admissions, and in some organizations, they admit 100 percent of patients. These physicians have multiple priorities and, attending clinical documentation training sessions, is often not on their “to do” list. What options are available to healthcare organizations to obtain cooperation from their voluntary medical staff for clinical documentation (CDI) training? You can use these suggestions below to begin building support from your voluntary medical staff.
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The Patient Record is Your Common Ground with Your Medical Staff
The common ground between the medical staff and healthcare managers is the information about the patient, which is contained in the patient’s record. Physicians need the information as their primary communication tool with each other in order to treat the patient. All physicians use the existing patient record when they are following up with the patient. They also use it for research. On the other hand, the healthcare management team uses the patient record for legal defense, quality measures, risk management, and planning. Further evidence of this symbiotic relationship occurs when the physician’s documentation is translated into coded data by hospital employees and used to determine how much the hospital will be paid.
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Reader Poll
Visitors were asked the following question and here are the results:
How would you describe clinical documentation in your organization? 51.5% - We have had a CDI program in place for 2 or more years
24.2% - We have had a CDI program in place for less than 2 years
21.2% - We are currently in the process of implementing a CDI program
3% - We do not have a CDI program in place and are not planning for one in the future
0% - We do not have a CDI program in place, but are planning for one in the future
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Who teaches your CDI training sessions for physicians?
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Did You Know?
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. Sample Job Description:
Clinical Documentation Manager
Documentation Example:
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