Though it may not seem like the most interesting of topics, the importance of clinical documentation to improve patient care seems to go under the radar among many healthcare organizations, regardless of size. In reality, this is actually an underrated means of improving your patient safety, as well as fostering a stronger relationship with them.

In essence, clinical documentation is a big file with extensive details of all your patient’s medical records/medical documentation. This contains fairly basic information, but important nonetheless – things like what their diagnosis is, how they’re currently being treated, and how they’re doing in general.

And, believe it or not, accurate documentation and how well that file is kept up-to-date make a substantial difference in how well any given patient is cared for, so it’s vital to maintain quality reporting when dealing with a patient’s medical record.

So, throughout this article, we’ll be breaking down some of the simplest ways you can improve clinical documentation for all of your patients with the aim of building a platform to provide quality patient care from. Let’s get started!

Using Clinical Documentation to Improve Patient Care

To kick things off, we’ll open with the various different ways healthcare providers across the country can use clinical documentation to improve patient care and relationships.

Identifying Areas For Quality Improvement

By looking over your clinical documentation, there are actually a lot of ways for your practice to find areas of potential improvement. As an example, your staff could review any patient records to determine whether or not the care they’re providing meets the patient’s needs, allowing them to take action if not.

Improving Patient Outcomes

Any data you’re able to extract from clinical documentation plays a huge role in monitoring and improving your patient outcomes in general. For instance, through analysis of a patient’s medical record, it’s a lot easier for your staff to see which treatments they’re responding best to and which approaches seem to be the most effective.

This’ll help you to adjust your patient’s individual treatment plans, helping to ensure they’re receiving the best possible care from your medical team.

Best Practices For Clinical Documentation

In this next part of the article, we’ll go over some of the basic ways you can start improving your clinical documentation, as well as explain how this can help your patients.

1. Accuracy Is Key

Above anything, accuracy is the name of the game when it comes to providing your patients with the best care. Upon any encounters with patients, it’s vital for your staff to document any patient information while it’s still fresh in their minds. Remember, this documentation should include a range of details, like medical history and the procedures/treatments they’re receiving.

Inaccurate documentation causes big miscommunication issues between healthcare providers, so stay on top of this to avoid any delayed or incorrect treatments for your patients that could frustrate them.

2. Clarity, Consistency & Specificity

Try to keep your documentation as blatantly written as possible to avoid any confusion or misinterpretation between any party. This means writing in standardized terminology when possible, helping to ensure that everybody involved in a patient’s care has a common understanding of medical concepts.

In addition, try to avoid using too many abbreviations too, as this also leaves room for ambiguity.

3. Outsourcing For Quality & Accuracy

Unfortunately, it’s not always that easy for healthcare professionals like yourself to keep track of all the details and make sure everything is recorded properly – especially if you’re a smaller medical practice without the resources and staff to dedicate towards it.

In addition to the time constraint upon you, the plethora of medical terms to memorize and adaptation to new technology can lead to poor documentation among your health and human services.

When you’re trying to create a clinical documentation improvement program, there’s no one you’d rather have by your side than an outsourced medical billing service to keep your coded data accurate at all times. These services boast an adept understanding of all things medical billing in the state of California, as well as having particular expertise in clinical documentation to improve patient care.

Improving Clinical Documentation With PMN

One such medical billing service that can offer assistance is PMN! PMN has over 20 years of experience helping small practices in the healthcare industry, with a team of experts specifically dedicated to clinical documentation/electronic health records. Outside of clinical documentation, PMN also specializes in reducing your A/R days, improving your patient collection management, and even generating custom reports for you to learn how to best optimize your practice’s revenue cycle management.

If you’d like to hear more about what PMN can do for your medical organization, get in touch with them today at (949) 215-5055, or visit their lovely office in sunny Laguna Hills, Orange County, California!

FAQs

How Can Healthcare Providers Ensure Their Clinical Documentation Meets Regulatory Requirements?

Throughout California and the United States, healthcare providers of all sizes must comply with the various regulatory requirements for clinical documentation, such as HIPAA.

Don’t worry if this sounds stressful to achieve – your practice can easily remain HIPAA compliant by seeking out any training and education opportunities around you, even including outsourcing to a medical billing service.

How Can Patients Be Involved In The Clinical Documentation Process?

In general, your practice should be encouraging patients to help as much as possible with the clinical documentation process, meaning reviewing and verifying their medical records for accuracy and completeness and asking questions about their treatments and outcomes.

This kind of collaboration leads to much more informed decision-making, so your patients can receive an overall higher standard of service.