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Clinical Documentation Services

Clinical Documentation

Essential Data Corporation can help your organization create and organize clinical documentation for compliance and efficiency while creating a culture of best practices

Anyone required to produce clinical documentation for their industry knows how tricky it can be to keep all of the information organized, accurate, and legally compliant while adhering to best practices. Simple mistakes such as forgetting the date and time can cause a loss of records while major mistakes can cause a loss of business or legal liability issues costing time and money.

What is Clinical Documentation?

The American Academy of Professional Coders defines Clinical Documentation as “…the information a person responsible for a patient’s medical care enters in a medical record, which is a repository for an individual’s health information. The entries contained in the medical record may be authored by a physician, dentist, chiropractor, or other healthcare professional. Regulations, accreditation requirements, internal policies, and other rules may define who is allowed to document in the medical record in specific cases”. Everyone who touches healthcare records is a Clinical Documentation Specialist.

Based on this definition, Clinical documentation is a task that can be completed by several healthcare professionals on many levels and touches multiple aspects of the organization. This documentation can directly affect patient care and revenue and can make the jobs of others easier or more difficult.

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Clinical Documentation Services

What Are the Benefits of Clinical Documentation Services?

The American Academy of Professional Coders (AAPC) suggests implementing a Clinical Documentation Improvement Program (CDI) to review documentation for accuracy to help ease the burden on administrative staff while increasing productivity and maximizing revenue. Adherence to HIPPA regulations is critical for a healthcare organization. The United States Department of Health and Human Services defines a “HIPPA Enforcement Rule” as “…the imposition of civil money penalties for violations of the HIPAA Administrative Simplification Rules, and procedures for hearings”.

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Other Benefits of Accurate Clinical Documentation

  • Improved Patient Care: Accurate and up-to-date documentation provides healthcare professionals with a clear understanding of a patient’s medical history, current condition, and treatment plan, leading to more informed and effective decision-making.
  • Continuity of Care: Well-documented patient records ensure that different healthcare providers involved in a patient’s care have access to consistent and relevant information, enabling seamless transitions between different stages of care.
  • Enhanced Communication: Comprehensive documentation allows for effective communication among healthcare team members, ensuring that everyone is on the same page regarding a patient’s condition, treatment progress, and any necessary interventions.
  • Legal and Regulatory Compliance: Proper documentation supports compliance with legal and regulatory requirements, protecting healthcare providers from potential legal liabilities and ensuring that medical practices meet industry standards.
  • Accurate Diagnosis and Treatment: Thorough documentation aids in the accurate diagnosis of medical conditions and appropriate treatment planning, as healthcare providers can analyze trends, symptoms, and responses to interventions over time.
  • Research and Education: Clinical documentation contributes to medical research, quality improvement initiatives, and medical education by providing data for analysis, insights into patient outcomes, and opportunities for training future healthcare professionals.
  • Reimbursement and Billing: Complete and accurate documentation is essential for healthcare facilities to receive appropriate reimbursement from insurance companies or government programs. Proper documentation supports the accurate reporting of services rendered and procedures performed.
  • Legal Protection: In cases of medical disputes, malpractice claims, or litigation, well-documented patient records can serve as evidence of the care provided, helping to establish the medical decisions made and actions taken.
  • Quality Assurance and Improvement: Documenting clinical information enables healthcare organizations to identify areas for improvement in patient care, clinical processes, and administrative procedures, leading to enhanced overall quality of care.
  • Risk Management: Through consistent documentation, healthcare providers can identify potential risks, adverse events, and complications. This enables proactive measures to mitigate risks and enhance patient safety.
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How EDC Can Help with Clinical Documentation Services

Whether you need a single technical writer for a brief project or a team of consultants to produce a complete line of clinical documentation, the quality of our work is guaranteed for you. Our clients work closely with an Engagement Manager from one of our 30 local offices for the entire length of your project at no additional cost. Contact us at (800) 221-0093 or to get started.

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