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What is Clinical Documentation

a doctor representing the importance of medical writing

Like a lot of technical work, clinical documentation details require deeper knowledge of the industry to comprehend its scope . 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. However “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; in the terms with which we are working, “space” applies equally to the real world as it does to the cyber world.

Computerized documentation is the primary option for company records. According to the American Health Information Management Association(AHIMA), computers “put less strain on physicians”  “put less strain on the physicians,” who spend time on patient-centered routines and visits.

Moreover, when it comes to clinical documentation, computers are part of larger processes of Clinical Documentation Improvement (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. They then 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. 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

Review them again, and you will find that these attributes 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. The AAPC listed accuracy first, as when accuracy is forgotten, the rest of the work cannot be considered.

What If Medical Details Are Out Of Order?

The systems for Tricare and the Center for Medicaid Services are not forgiving of mistakes with billing claims. The date of service and diagnosis codes must be correct and 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

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. 

We have teams of consultants ready to produce a complete line of documentation. Perhaps you may only need a single technical writer for a brief project. Either way Essential Data’s Engagement Manager will lead the project from start to finish. At Essential Data Corporation, we guarantee the quality of our work. Contact us today to get started. (800) 221-0093 or

By Will Boswell

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