Volume 1

Research Support for the Need to Improve Clinical Documentation Industry-Wide

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The ability to ensure that an input creates the desired output is essential in every business. In the business of healthcare, one essential input is the clinician’s documentation and the desired output is reliable and accurate health information. In the business of healthcare, budgeting and spending is based upon documentation provided by physicians for the care they provide to patients. Moreover, poor quality documentation in a patient’s record has been linked to both excessive healthcare costs and poor quality of care. The converse has also been found to be true, that high quality clinical documentation results in more reliable data and higher quality care.

There is a significant amount of literature relating to the poor quality of clinical documentation in an inpatient medical record. The evolution of clinical documentation research is at the very early stages. Most studies on lack of quality in clinical documentation have focused on identifying the problem without including suggestions for improvement based on empirical findings. The CAMP™ Method Clinical Documentation Training Study, however, successfully applied a training methodology and showed, through regression analysis modeling, improvement in the documentation practices of clinicians involved in the study. The complete statistical support for the CAMP Method training is presented several chapters of Volume 1.
 
The current research available on clinical documentation reveals that lack of adequate documentation is a problem throughout the industry. Studies have found inadequate or absent documentation in up to 70 percent of patient medical records. Research has also found that the most significant documentation deficiencies occur in patients with long lengths of stay and with complex diagnoses.  Furthermore, the research studies identified that obtaining complete documentation while the patient is still in treatment results in higher quality documentation. 

Chapter 2 contains a synopsis of the current literature published on the challenges associated with attaining high quality clinical documentation, objective proof of the need for all healthcare organizations to implement CAMP™ Method Clinical Documentation Training for physicians.

References:

Carroll, Tarczy-Hornoch, O’Rielly, & Christakis (2003)
Cascio, Wilkens, Ain, Toulson, & Frassica (2005)
Mulvehill, Schneider, Cullen, Roaten, Foster, & Porter (2005)
Novitsky, Sing, Kersher, & Griffo (2005)
Rhyne & Gehlbach (1979)
Rifkin, Berger, Holmboe, & Sturdevant (2007)
Socolar, Raines, Chen-Mok, & Runyan (1998)
Stengel, Abauwens, Walter, Kopfer, & Ekkerkamp (2004)
Wong, McCarron, & Shaw (1983)