With the improvement in every section of the healthcare industry, the need of investing in clinical documentation has become necessary. Plus, healthcare facilities have made it mandatory to record accurate medical coding and clinical documentation. Healthcare organizations require quality metrics to ensure high-level patient experience. This is where the provision of precise care and accurate clinical documentation with accurate coding guarantee timely reimbursement and high-level patient care.
What is Clinical Documentation?
Clinical documentation starts from the core of the patient’s first encounter. To get a precise look at the clinical documentation, they must be clear, complete, reliable, consistent, legitimate, and reflect the accurate burden of the services rendered to the patient.
Experienced clinical documentation integrity programs are responsible to represent the clinical status of the patient which eventually translates into medical coding. These medical codes will be further used for billing, reimbursement, report cards, disease tracking surveys, trending and tracking, multiple medical research, and for public health data.
The conjunction of the clinical documentation according to the guidelines and accurate coding procedures is vital for quality scores, leveraging quality patient care, and making informed decisions. In addition, the clinical documentation integrity programs directly impact the information provided to the members involved, the care team, and the professionals that may be treating the patient in the future or at a later date.
Clinical Documentation Records
In the medical healthcare industry, the uses and needs of clinical documentation have dramatically increased in the last twenty-five to thirty years. As discussed, the clinical documentation is used for medical trials, treatments, and tests that would be reimbursed using the detailed coded data for these services. However, it is important to understand that this data is applied for the provided diagnosis in claims as medical procedure evidence and coverage and would not lead to providing any end result or a particular diagnosis. The data may suggest that the patient needs further medical assistance and if they qualify for any other treatment or procedure. Therefore, clinical documentation for patient encounters has been one of the major foundations for maintaining patients’ health records.
Why are the Records important and How are they used?
Clinical documentation is mainly focused on assisting inter-provider communication, creating registry functions smoothly for patients, automate the healthcare systems based on evidence and proofs. This way, public health record-maintaining agencies can populate the data more efficiently.
Clinical documentation also sums up the entire data and the healthcare information of the patient from all sources in order to evaluate claims. Besides, healthcare research dependence on clinical documentation has a significant impact on the provision of healthcare services in the future. This research is further used in organizational structures, financial systems, health technologies, personal behavior, healthcare organizational procedures, and clinical data. Every data gathered from the research is then transcribed and gathered to prepare accurate clinical documentation.
What is Non-clinical Documentation?
Non-clinical documentation is the one that involves administrative information necessary for the care process. As a result, non-clinical documentation is taken as those that facilitate organizational coordination for smooth and good management of all the means for available resources. Different types of clinical documentation help practitioners to make informed-decision.
Types of Clinical Documentation
1. Patient Information Leaflet – PIL
A PIL can be found when you get medicine from a pharmacy. In this piece leaflet, you get all the prescribed medicine, frequency, important information, side effects of the medicine, conservation, and doses.
2. Medical History Record
The medical history record includes information about the patient’s past and present medical conditions, treatments, and procedures. The record is used by healthcare providers to make decisions about the care and treatment of the patient.
The medical history record is a confidential document. The patient may request a copy of their medical history record, and the healthcare provider must provide the patient with a copy if requested.
3. Discharge Summary
A discharge summary is a report that is created by a doctor when a patient is discharged from the hospital. It includes information about the patient’s hospital stay, diagnoses, treatments, and any other important information that the doctor wants to share. The discharge summary is then sent to the patient’s primary care doctor so that they can be up-to-date on the patient’s health.
4. Operative Report
An operative report is a report of the surgical procedure performed by the surgeon. It includes a description of the patient’s condition before surgery, the operative procedure, and the patient’s condition after surgery. The operative report is an important document that is used to record the surgeon’s findings and conclusions. It is also used to communicate the surgeon’s findings to other members of the surgical team.
Clinical documentation is an important document that is necessary for making healthcare treatment plans. This documentation also helps in making accurate reimbursements for the rendered services. If you need help in making one try medical coding services for smooth and regular claim reimbursements.