Improving Patient Care with Clinical Documentation

What is Clinical Documentation

Like a lot of technical work, clinical documentation has a name that, at first, may cause much confusion. It describes its purpose but is also slightly vague and general. Looking to the superficial, the name seems to contradict the specificity of the technical writing genre. It needs more details, more acronyms, and more punctuation — at the same time, it does happen to be clear, succinct, and preparative. The first guess that comes to one’s mind when studying the name is the right one. It does have to do with the medical field, but “clinical” can mean more than “hospital,” just as “documentation” means more than “patient notes.”

The Basics of Clinical Documentation

Dentist’s offices, urgent cares, and veterinary clinics, all follow the process of documentation, although they highlight different types of information. Sometimes this documentation takes the form of ICD-10 codes or perhaps for therapy, treatment and evaluation codes, and sometimes they may also be patient notes containing medication lists and allergies. Despite case-by-case differences, every example I have just listed is sensitive patient information protected under the HIPAA Act of 1996. In order to ensure confidentiality, security has to be set up in not just one area of a medical office, but in all of them. To put it one way, privacy starts at the front door, and in the terms with which we are working, “space” applies equally to the real world as it does to the cyber world. Indebted as we are to paper for how it has contributed to societal development, it is, next to the digital advances of the last sixty years, the secondary option to computerized documents. Computers and their revolutionary, albeit limited, storage, according to the American Health Information Management Association (AHIMA) “put less strain on the physicians,” who will likely want to spend their time on patient-centered routines and visits.

That previous sentence would seem to have it that computers are, again, the century’s greatest innovators, a title which indisputably has merit, but when it comes to clinical documentation, computers are part of larger processes of Clinical Documentation Improvement (hereafter referred to as CDI). In fact, the North Carolina Healthcare Association (NCHA) has designed a four-phase process for Clinical Documentation Improvement. Assessment takes place first, with Design coming second, followed by Education, and finally Monitoring. As they sound, so they are; for example, Assessment can consist of diagnostics and accuracy checks. From there, they feed into one another: Design leads into Education, and Education leads into Monitoring like a version of the scientific method with about a quarter of the steps.

What should Clinical Documentation Contain

What Should Clinical Documentation Contain?

Now, we might still refer to all of this as clinical documentation, since it does the job well enough, however, to have a uniform list makes for greater particulars and reviewable standards. Think SOPs, and more than that, think of them in connection to information and routines that keep track of states of health. Significance sometimes comes of proximity to death, and medical procedures, at times, are valuable to some people by virtue of their being the acts that will keep them alive a little longer. 

The standards can and will vary, but for a good idea of what to expect from a good model, we might consider the American Academy of Professional Coders’ (AAPC) requirements for a clinical documentation program:

  • Accurate claim submission
  • Favorable audit results
  • Healthy revenue cycle
  • Better health outcomes

Take a look at the adjectives. Each one’s goal is to improve. Review them again, and you will find that these adjectives also describe a trustworthy healthcare provider. From diagnosis to discharge, doctors take treatment quite seriously; apply that attitude to documentation, and suddenly, grammatical errors look unacceptable, given the power those papers wield. Doctors and documentation operate in a symbiotic relationship wherein one cannot do its job correctly without the other doing the same. There is a reason the AAPC listed accuracy first, as when accuracy is forgotten, the rest of the work, no matter how well done on its own, cannot be considered.

The systems for Tricare and the Center for Medicaid Services are, by nature of their automation, not forgiving of mistakes with billing claims. Not only must the date of service be correct, but the place of service and the diagnosis codes also have to line up with each other. Imagine that a detail is out of order, and your medical office does not receive payment. To make it worse, what if there is no history of submitting a claim? Do you start over? Do you reexamine everything — that is, the notes, the times, the providers, the equipment, and the outcomes?

Generally, yes, and you know that. You have had to endure it at some point.

In 2019, the CDC wrote up different recommendations on how to manage health records, with the idea being that in following their advice, medical offices can get away from troubles with details or security. HIPAA never leaves your side, and to be clearer, it never leaves your side if you are qualified to access HIPAA-classified documents. It is up to you to decide who needs access to which records. Of course, the best course is probably to limit that circle as much as you can because that way, the list is of few enough people to remember.

We Can Offer You Assistance

Whatever your needs in this area, and maybe it is a different area, too, Essential Data Corporation will be here to help you see your goals met. Consider the “Essential” in our company name: security is our priority, as is accuracy. In the medical field, each piece of data is a bit of a person’s life, and we understand that. 

Whether you need a team of consultants to produce a complete line of documentation or a single technical writer for a brief project, Essential Data’s Engagement Manager will lead the project from start to finish. At Essential Data Corporation, the quality of our work is guaranteed. Contact us today to get started. (800) 221-0093 or

By Will Boswell



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