In these times when the importance of clinical documentation is highlighted because of the different changes in medical standards, there is a need to implement clinical documentation improvement programs that will help maintain the quality of health care services and at the same time acquire maximum benefits from the services rendered. There is also a need to maintain reliable documentation that would serve the purposes well. In doing so, the entire process becomes somewhat complex and thus requires the expertise of a CDS or clinical documentation specialist.
This professional is originally considered as administrative personnel in charge of the creation and maintenance of medical files which includes patient’s medical records, health histories, and documents. They are usually found in hospitals, private clinics and medical offices. Now they are expected to perform pivotal roles in the implementation of a clinical documentation improvement program.
The usual clinical documentation procedure already offers a wide scope of responsibilities to a clinical documentation specialist. A CDS along with other HIM or Health Information Management staff will be in charge of making sure that accurate documentation is obtained. From the time of admission, vital information has to be gathered from the patient as much as possible. If the patient is unable to respond, the closest relative can provide some details.
Medical records personnel will coordinate with physicians or interact with patients directly to obtain the necessary information and this must be done as quickly as possible so that the most appropriate medical plan can be developed. Also, insurance coverage and other exceptions will be arranged after identifying the severity of the illness. Medical records will be evaluated by a CDS and just in case some errors and ambiguities are identified, the necessary clarifications are made right away.
Just like the medical field faces the continuous challenge of providing better solutions and medical services, a clinical documentation specialist faces some challenges and barriers in the area of clinical documentation. One would be the changing standards and the regular revisions that are related to applicable DRG codes and other standards that may have a big impact on documentation.
These revisions can literally make documentation practices obsolete and so a CDS faces the challenges of making the appropriate adjustments according to a clinical documentation improvement program being used or the recommendation of a conducted medical record audit whichever is more effective in making the procedures up to date. Also, terms and communication barriers between physicians and coders have to be resolved.
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It is clear that one of the ultimate goals for medical institutions is to provide safe and quality health care and medical services. It greatly requires teamwork and the cooperation of each member of a medical organization to ensure that all areas are free from risks and errors that may affect the welfare of the patients involved. Most of the services, procedures, and practices are based on standards as dictated by medical records. It is therefore important to observe proper clinical documentation to ensure organized and systematic workflow inside a hospital or clinic.
The outcome of a medical service depends on the expertise and capabilities of medical professionals. Teamwork is essential to carry out the needed plans and medical operations efficiently and effectively. While most hospitals focus on guarding the qualifications of the doctors, nurses, and other clinicians, an important member of a medical organization is often left out.
A clinical documentation specialist is one of the crucial members that will promote quality and organized health care services as medical teams can benefit a lot from reliable medical records and documents. A lot of high standard hospitals implement clinical documentation improvement programs suitable to them and one of the basic suggestions is the pivotal roles that will be performed by a medical professional who is not only well versed with medical operations and standards but also with administrative and clinical documentation. The roles of a clinical documentation specialist is quite demanding as the new tools involved in modern clinical documentation requires a professional who can handle modern programs, software, and other products of medical information technology.
Safety and quality medical services used to rely solely on medical professionals but this created a lot of gaps since medical professionals couldn’t possibly provide two separate responsibilities while ensuring quality. We are referring to the medical responsibilities that they already have and their tasks to document everything and what about archiving, securing, encoding, and documentation of important medical records? Through the suggestions of a medical records audit, clinical documentation improvement programs are introduced. As a result, a new member of the medical team is introduced.
A clinical documentation specialist will complete a team dedicated to ensuring safety and quality when it comes to medical or health care services provided on a daily basis. This will come from effective workflow as affected by medical records that are reliable, accurate, secured, complete, and accessible.
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People would logically choose a hospital or a health center that is reliable whenever they are in need of medical services. This is just like the way you would want to have the best medical attention and timely recovery from any medical concern and diseases. A medical institution is involved in an industry where there should be no room for major errors since lives are at stake.
A medical institution can further evaluate the quality of the services being provided through the feedback they get from the patients and of course through the figures on the overall revenue. Thus, providing quality health care is the ongoing challenge for medical professionals. This is something that can be achieved through organized and systematic daily operation based on effective medical record keeping in which clinical documentation improvement specialist plays a big role.
Improvement programs are becoming the basic necessities of medical institutions to meet the changing medical demands of the society. A high quality medical service is only possible if reliable data is provided. This can be in the form of diagnosis, observation, tests, procedures and many others. If they are all put in into records to be secured and be of good use anytime, then they are collectively called medical records or clinical documents. A lot of medical plans, procedures and solutions depend on the reliability of clinical documents.
To ensure that high quality medical service is provided, the aspect of documentation must be given enough attention through clinical documentation improvement program. The programs and tasks involved will ensure systematic and organized workflow through effective documentation. Clinical documentation is expected to contain all important details about a person’s health and condition including all the information about the medical services provided. It is governed by certain regulations and standards so compliance must be observed as it will reflect the reputation and credibility of a medical institution.
Through various tasks and suggestions provided by a CDI program. It is now possible to achieve the highest quality of medical services as characterized by reduced hospital stays and timely recovery for the patients. To make sure that proper programs are adopted, a hospital must base all decisions from the conducted medical audits where improvements and corrections will be determined. Medical personnel can then determine the most effective practices that will benefit not only the patients but also the men and women of a certain medical institution.
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