Clinical documentation improvement (CDI) is important for good health care because it:
- Improves Patient Record Quality
- Ensures Proper Reimbursement
- Provides “Big Picture” Data
- Reduces Documentation Errors that Can Impact Patient Health
Medical transcription services from iMedat help you improve your CDI efforts. Our professional medical transcriptionists are clinical documentation experts who play a key role ensuring that your patient records are complete and accurate while reducing the risk of errors.
Clinical Documentation Improvement (CDI) is Important Because…
The idea behind “Clinical Documentation Improvement” or CDI is not new. Creating and maintaining accurate patient records is almost a field unto itself, developing over the last 270 years or so.
However, CDI has come to the forefront more and more in the last several years. That’s likely because our records are becoming interconnected more than ever with electronic medical records (EMRs), also known as electronic health records (EHRs). Computerization opens new avenues to improved patient care including record portability as well as advanced metrics and accountability tracking. This allows health care providers to see macro trends that help them make improvements at the patient level.
Although electronic records sound good in theory, the reality is that different organizations from hospital networks to single physician offices tend to use different EMR software – and that software doesn’t always play nicely together. To complicate matters, some physicians still use paper-based records because they find it faster and easier for their own practices.
As we’ll see, clinical documentation experts can help CDI, no matter what system you’re using. But first, the top four reasons why clinical documentation improvement (CDI) is important:
CDI Improves Patient Record Quality, Leading to Better Communication and Patient Care
The core goal of the patient encounter is to diagnose the problem and provide appropriate care. The way clinicians document these encounters is key to that goal – especially for clinicians working in large health networks. Patient documentation is almost like a language unto its own. Clinicians need to say the right things in the right way for others to understand them. These “others” include other health care providers, network administration, and patient and care pathway navigators – not to mention billing (more on this below).
In other words, where in the patient record you put information is just as important as what information you add. An obvious example is structured vs. unstructured data: misfiling structured data in unstructured fields can mean the data is not captured in the most meaningful way. This potentially reduces the level of patient care.
Improving CDI means that care can be better matched to need and in turn lead to improved patient care and outcomes. It will also reduce the risk of a patient falling through the cracks due to miscommunications.
CDI Ensures Proper Reimbursement
Clinical documentation improvement (CDI) is important for the business side of health care as well. The reality is, improper documentation leads to improper coding and incorrect reimbursements. That’s a problem whether you are a single office or part of a larger hospital or clinic.
“Ninety-five percent of ensuring appropriate reimbursement is just good documentation practices,” said Dr. David Schillinger, Chief Medical Officer for SCP Health. “The other five percent consists of learning the rules provided by the federal government and other organizations that we need to know from a documentation compliance standpoint so that we are reimbursed correctly.”
As we’ll see below though, documentation compliance can be difficult for clinicians for several reasons. (Luckily, help is at hand as we’ll also see…)
CDI Provides “Big Picture” Data
One of the greatest advantages of computerization is the ability to store, compare, analyze, and manipulate data in a way that allows us to see the “big picture.” This includes measuring aggregate data such as performance metrics and quality indicators as well as real-time analysis of estimated length of stay (ELOS), bed utilization, and more. Data can also be used to see trends over time including infection rates, mortality rates, incidence rates of particular diseases, and quality scores during specific time periods.
Obviously, macro data is only as good as the micro data it’s based upon. Poor clinical documentation at the patient level leads to inaccurate and even misleading data at the big-picture level.
CDI Reduces Documentation Errors that Can Impact Patient Health
Of course, this is related to the first point about improving the patient record. But it’s worth underlining since it can directly impact patient health. These documentation errors include med rec errors, unclear or incomplete instructions, incorrect abbreviations, adding information into incorrect fields, missing information, and more.
CDI systems that use clinical documentation experts reduce these errors in two main ways:
- They are the experts that can help ensure the right information is documented in the right places
- Their knowledge of medical terms allows them to provide another set of professional eyes on patient records, flagging potential errors including abbreviations and missing information
Clinical documentation improvement (CDI) is important for reducing documentation errors, which in turn can improve patient health.
How Medical Transcription Improves Your CDI
However, one of the principal barriers to proper documentation is physician and clinician buy-in. This can be due to many factors including lack of understanding, lack of time (and accompanying physician burnout), lack of training, and lack of desire to change what’s been working for them for years or decades.
This “lack of” sounds like clinicians should be doing more, but don’t blame the clinician for a faulty system. Data entry, coding, structured data – all of these can be foreign terms to clinicians. They are trained to provide health care to patients, first and foremost. They are not necessarily trained in the finer points of data processing.
Medical transcriptionists, on the other hand, are trained in proper documentation as well as medical terms. Medical transcriptionists are the link between great patient care and great documentation of that care.
One of the key ways medical transcriptionists support clinicians is that they can help ensure patient encounters are documented in a way that will facilitate:
- Better communication by improved data capture
- More accurate reimbursements by ensuring medical coders have the data they need
- Better macro data from better patient data
- Reduced risk of patient injury and malpractice suits
Physicians and clinicians are finding out that EMR systems are not as easy to maintain as once thought. They spend many more hours updating patient records, cutting into either their clinical time or personal time. Neither is acceptable.
A robust clinical documentation improvement plan should include better clerical support for clinicians. This will not only improve patient recordkeeping but it will improve quality of work and life for clinicians, too.
Contact iMedat to Advance Your Clinical Documentation Improvement Efforts
Clinical documentation improvement is important, but it’s not always easy. Contact iMedat or call toll-free 888-779-5888 to find out how adding our medical transcriptionists to your team can help your clinical documentation improvements in very measurable ways.