A Compelling Case for Clinical Documentation: Volume 1

Use patient records to achieve strategic alignment with your medical staff

Volume 1 of this series provides a strategic approach to improving content of patient records through hospital-physician relationship development and physician training. Some may argue that clinical documentation is too operational to be included in a discussion on strategy. Peter Drucker describes strategy as the means for converting The Theory of the Business into performance. In the case of healthcare, the patient record is the essence of the business. It is where all theory, practice, communication, thoughts, and activity converge. It is the common ground for everyone involved in the business of healthcare. Give it the best care and feeding and your business performance is likely to improve in the form of quality indicators, accuracy of reimbursement, reliability for legal and compliance purposes, use for planning and research and, most importantly, increased healthcare consumer confidence and quality of care as well as decreased compliance risk.

• Why Should I Care About Clinical Documentation?
• Research Support for the Need to Improve Clinical Documentation Industry-Wide
• The Economics of Clinical Documentation
• A Clear Vision
• Yin-Yang of Hospital Management
• A Common Definition
• A Meeting of the Minds, or Who Is Responsible
• Clinical Documentation Quality Applies to All Settings
• Training: Your Best First-Line Approach for Clinical Documentation
• Study Statistical Results and Analysis
• Testing Mechanisms
• Track and Measure Activities
• Continuing Education Components
• Keep the Patient at the Center of the Process
• Clinical Documentation and Strategic Considerations for the EMR
• Revisit the Vision: Possibilities for Clinical Documentation and Intellectual Capital