Clinical documentation in the health record is at the core of health care — it tells the story of a patient’s journey through the health care system. Ensuring this information is accurate is essential to quality patient care.
Within health care, data is limitless. Whether it is clinical, administrative, financial or patient-generated, the need to manage that data efficiently is now more important than ever. New electronic data capture methods such as mobile health apps, patient self-monitoring, wearable devices, patient portals and health information exchanges have led to a dramatic increase in the ways health care organizations acquire patient data for use in the electronic health record (EHR) — increasing the need for clinical documentation improvement/integrity (CDI) programs.
Keeping the record consistent
The purpose of a CDI program, which most U.S. acute care facilities have, is to initiate concurrent and, as appropriate, retrospective reviews of health records for conflicting, incomplete or nonspecific provider documentation. These reviews usually occur on patient care units, in outpatient clinics or are conducted remotely via the EHR.
The diagnoses and procedures documented in the record need to be clearly supported by clinical indicators so the codes assigned are accurate, resulting in quality data reporting and accurate reimbursement. Complete and accurate clinical documentation is also essential for disputing denials and receiving appropriate reimbursement. Providing quality patient care is the most significant outcome of improved clinical documentation.
A lack of adequate clinical documentation is a problem throughout the health care industry. Coupled with low health care literacy, this can produce ineffective care plans that patients cannot maintain.
While high-quality documentation is always sought, it remains uncommon within most health care settings. CDI programs are the bridge between a host of institutions, such as health care, case management, coding professionals, quality management and financial services.
To ensure high-quality clinical documentation that can be trusted, organizations must also have data and EHR integrity. Documentation and data content within an EHR must be accurate, complete, concise, consistent, timely and universally understood by data users. Both structured and unstructured data must meet a standard of quality if they are to be meaningful for internal and external use, especially for the continuum of care. Factors such as ease of use and design of the EHR can facilitate adherence to documentation guidelines and standards.
Health information management (HIM) professionals are trained extensively in clinical documentation requirements, EHR implementation and management, and data quality practices. Health care facilities should be looking to the HIM professionals within their organization to ensure high-quality patient care through managing the integrity of the documentation, EHR functionality and access, and data quality.
Melanie Endicott, Vice President, HIM Practice Excellence, American Health Information Management Association, [email protected]