Clinical documentation improvement program is becoming more and more common in hospitals as they are realizing the importance of proper documentation in the running of the organization. The following article describes the various types of clinical documentation being used.
A noticeable revolution is taking place in the way health care sector is rated and reimbursed. New laws are also being introduced making hospitals sit up and take notice. This turnaround in the health-care performance evaluation and compensation has made the documentation process very decisive and significant. Regulatory reforms are throwing light on the importance of maintaining accurate clinical documentation. The kind of reimbursement is directly influenced by the patient’s true records which has well portrayed all relevant data. Thus, the need for clinical documentation improvement program to address the above issues and to avoid unnecessary inquiry into the general scheme of things.
The focus of documentation teams should be to enhance the quality and safety of patient care. Most clinical teams depend on physician documentation to identify the diagnosis and risk factors. However, such documentation may be ambiguous, incorrectly stated or sometimes even missing. Many hospitals are now recognizing the importance of a clinical documentation improvement program to lay emphasis on the value of quality care and precise documentation. Clinical specialists are being inducted into the clinical team to give a new impetus to the documentation practice.
A clinical documentation improvement program typically begins with an assessment of your DRG based records and the documentation requirements. It helps identify quantifiable objectives for your CDI program. The program manages every feature of CDI, right from customizing the technology and incorporating it into your current system, to ensuring that the hospital staff understands the program and implements it successfully. In-corporations which specialize in CDI programs are being roped in by hospital administration to manage and scrutinize the program and to ensure that its objectives are met. A CDI program educates the hospital staff by providing strategies and approaches that aid them to document each patient’s case from the very moment he or she enters the hospital. Most programs provide a process that summarizes the difficulty levels and is replicated in your Case Mix Index.
A good clinical documentation improvement program ensures that the documentation is in accordance with The Coding Clinic and ICD-9-CM Official guidelines. With a proper CDI program in place, it would be easier to make sure that the documentation supports apt reimbursement and prevents the risk of non- compliance. CDI program helps to improve quality of care with specific documentation. This helps in better identification of quality core measures, decreased medical errors in treatment and lesser risk in legal matters. However complex the diagnosis may be, with superior documentation standards, the higher will be your reimbursements. CDI programs also defend you against RAC audit liability risk.
Thus, a comprehensive clinical documentation improvement program can bring about a drastic improvement in the overall efficiency of the hospital and produce long term positive results.
