Suggestions for Clinical Documentation Improvement

Check out Vice President of Revenue Cycle Services Keith Olenik’s top 5 strategies for clinical documentation improvement. Let’s get right to the point:

  1. Review your documentation. Look at the workflow and the existing templates to drill down and identify variation. That allows you to then make recommendations for standardization. Physicians are going to ask for that, so you have to have that data. 
  2. Get physicians support. Clinical documentation improvement will not happen without physician support. Give them the information, the feedback and the data. Getting their buy-in is the only way you’re going to be able to implement standardization.
  3. Look at the technology solutions. Are you utilizing all the functionality within the technology? When you implement a system, the vendor provides you with good information, but then there’s the optimization phase. Maybe you didn’t know what questions to ask to know how to utilize the system, or they glossed over the information. Really evaluate the technology and figure out how you can utilize it better going forward. Additionally – are there other things, such as artificial intelligence, that can add to the physician documentation process?
  4. Create formal guidelines for documentation. Even going so far as requiring physicians / clinicians to get approval of the template they are going to use in the record, from content to how they’re going to document. It’s important to return to a “form concept” — even though it’s electronic today. 
  5. Fevelop the education materials for everybody who’s involved in the process and continue to provide that education. Also, have the resources available. Not every physician uses a computer as easily as others do. You must make sure they know how to use the technology, in addition to the procedures on how to document.

While improving your clinical documentation is essential, it’s really only half of the equation. Listen to Keith’s advice on achieving interoperability by striking the right balance for organizations’ need for standardization and physicians’ need for flexibility in episode 1 of our podcast, “Get to the Point.”

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