Striking the balance between organizations’ and physicians’ needs can be a challenge to achieve standardized clinical documentation and, ultimately, interoperability. Check out practical advice from our expert, Keith Olenik, VP Revenue Cycle Services:
Take stock and do an evaluation and assessment. You have to see how bad it is before you can go to your clinicians and say, “We have an issue, let me show you some examples.” Remember, physicians like data.
Next, you need to educate yourself. After you’ve looked at the clinical documentation, what are your recommendations going to be on how you address the problem? To even know that there really is a problem, you need to educate yourself.
A standards organization, HL7, has developed templates with input from a variety of organizations and clinicians. These are standardized templates that you could use and incorporate into your EHR. One specific template references the Consolidated Clinical Document Architecture, or the CCDA.
The CCDA provides a standard set of information (if it’s all captured) when a patient transitions from one provider to another. If implemented properly, it has been proven to ensure continuity of care with no gaps in information, no gaps in communication and, most importantly, no gaps in treatment.
Listen to more of Keith’s practical advice on clinical documentation improvement in episode 1 of our podcast, “Get to the Point.”