If asked why is good clinical documentation essential, what would you say? Many clinicians respond by highlighting that patient care facilitates communication between providers. Clinicians also understand the legal implications and associate well with the common phrase, “If you did not document it, then it did not happen.”
Clinical documentation serves a multitude of other purposes including safety reporting, population health analysis, medication management and hospital financial reimbursement. Without recognising how critical this documentation is to both the patient and hospital supply chain, clinicians are not aware of the full implications of how widely their documentation is used.
Clinicians are not to blame. Many clinical staff is provided with paper based tools such as the anaesthetic form below, it is reasonable to assume that this approach results in limited actionable and reliable data output.
Moving to a written online form, such as one in PDF, provide marginal improvements. They produce more legible copies of information, but they remain slow to recall and lack reporting capability.
What then do clinicians need to consider for effective clinical documentation?
Patient data analysis kicks into full gear after any episode of care. Hospital managers are mandated to provide regular reports to government agencies for quality and safety metrics. These reports are linked to funding. Clinical coders review patient files and match clinical diagnosis data detail for reporting in health fund reimbursements.
Many challenges can and do occur after an episode of care if the clinical diagnosis is incomplete, as it is not mandatory to document the specificity within a clinical diagnosis. An example of this would be a physician documenting congestive heart failure that was not otherwise specified when the hospital requires a specific diagnosis of acute systolic congestive heart failure to have greater accuracy of coding and billing. This difference may result in a delay or even a reduction in hospital reimbursement. On a larger scale, this means inaccurate government reporting and subsequent funding changes for hospitals, research and community programs.
Your Data Transformation
Clinical software tools can help facilitate clinical documentation and have been proven to do so. Just to be clear, enhanced clinical documentation does not mean making every field mandatory. Software solutions must be clinician and patient friendly with a standardised approach resulting in accurate data collection. This clinical data can then be analysed, transformed and reported back to the clinical team with accurate and meaningful outcomes. Hospitals also must be equipped to accept clinical feedback and develop a continuous loop of enhancements and improvements to respond to actionable clinical feedback.
Getz Clinical Cloud New Case Summary Release
Getz Clinical has provided Perioperative Information Management Solutions for almost two decades, with implementations in 55 hospitals worldwide. Our fully managed solution, Getz Clinical Cloud, has been designed ‘in the twenty-first century, for the twenty-first century’ utilising secure and reliable cloud technology. Our clients employ continuous learning techniques in conjunction with a system that is regularly updated. Hospitals enjoy a continuous innovation focus that takes clinical feedback into consideration. As healthcare evolves so do the solutions on offer to our clients.
Working within the capital intensive and static software product cycle is a thing of the past with our clients, as is for major upgrades. Getz Clinical customers are requesting better understanding of their data in a meaningful way, we are on a journey to drive better perioperative outcomes for our customers.
With our latest release, Getz Clinical has provided a more detailed Case Summary report because of enhanced clinical coding requirements from our clients. This report has been designed to provide all staff with a clear understanding of the case details for (1) medication management (2) equipment (3) complications and (4) chronological understanding of the case. This facilitates better internal communication, helping hospitals report quickly and accurately to third parties including their insurance companies.
To obtain further details or learn more about our clinical solutions, please contact firstname.lastname@example.org
 Towers, Adele L. “Clinical Documentation Improvement—A Physician Perspective: Insider Tips For Getting Physician Participation In CDI Programs”. Bok.ahima.org. N.p., 2017. Web. 28 Feb. 2017