Date
James Smith, MD
214 Elm Street
Providence, RI 10034
Re: Clinical Documentation Program
I hope you were able to attend the medical staff meeting last week where I described the hospital’s clinical documentation program, which will begin in March. I wanted to provide you with some additional detail about the program. As well as the benefits to our organization overall, the program will provide you with some documentation training opportunities that you can use in your private practice as well as with patients in the hospital.
Research has shown that physician clinical documentation in patient records is directly linked to quality indicators, quality of care, and the efficiency of healthcare operations. In addition, patients are twice as likely to request and read copies of their medical records today than they were 10 years ago. And, under HIPAA patients have the right to request modifications to their health information. Based upon this research and our desire to maintain high quality care and high levels of patient satisfaction, we are implementing a clinical documentation program. This program teaches the criteria for high quality clinical documentation and program staff use the criteria to review patient records for opportunities for improvement.
I am asking for your support of this clinical documentation initiative. Your responsibilities to the program include attendance at an initial documentation training program and continued attendance at follow-up training two to three times per year. In return, the hospital will provide you with lunch or dinner and CMEs for every hour of training you attend. In addition, you may be asked to clarify documentation in your patient records by one of the clinical documentation specialists, who will be located on the nursing units. If asked, you will need to clarify your documentation in the patient’s record.
If you have any questions about the program or would like additional information on the research conducted to justify implementing the program, I would be happy to share that with you. You can also find additional information about the program, including program staff names and contact information, in the physicians’ lounge and in the current medical staff newsletter.
Thank you for your time and involvement in this process. I appreciate the work you do with our healthcare system and the contributions that your practice of medicine makes to our community.
Sincerely,
James Smith, MD
CEO
cc: CFO, CMO, CIO, Compliance Officer (Oversight Committee Members)
