Volume 1

Why Should I Care About Clinical Documentation?

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A healthcare organization’s most valuable asset is its clinical information. This information is created or influenced by the physicians on your medical staff through their documentation and clinical practices. While you may not be able to affect the way physicians practice medicine, you and your organization have the ability, and the obligation, to shape the way they document.

Examples from every industry show that information, when properly used, can deliver a clear impact on measures such as cost, cycle time, productivity, and profitability. In healthcare, clinical information takes on a special property. While your organization’s clinical information may be used to increase profitability or productivity, it can also be used to identify specific strengths of your organization. These strengths can then be communicated to the community, to improve the stature of your organization. For example, you can do this by publicizing the numbers of surgeries performed by your surgical teams and the number of patients you treat for certain conditions. These numbers, especially over time, can impact consumer decision making when it comes to choosing a healthcare provider.

You already know how many organizations and individuals outside of your own are interested in the clinical documentation in your patient records. Here’s a general rundown of the main players in this quest:

• The healthcare team treating the patient. The patient record is the primary communication tool for all clinicians caring for the patient.
• Claims against the team or the hospital. The patient record is a legal document, kept in the normal course of business and is, therefore, discoverable in any legal action.
• Health plans and Centers for Medicare and Medicaid Services (CMS). The patient record is evidence that the bill submitted to the health plan, Medicare or Medicaid was for care that was actually provided to the patient. If the care is not documented in the patient record, health plans and the government consider that it was not provided and will, therefore, not pay for the service.
• Research studies and reporting. Researchers and government entities use the data, translated from the patient records by hospital or physician employees (coders), to understand, treat, and prevent illness, and promote the well-being of society in general.
• Healthcare planning. Aggregated data obtained from patient records through the coding process help to determine where communities need more (or fewer) healthcare organizations and to identify the most urgent healthcare priorities.
• Quality measures. Internet-based quality measurements resources like that used for Medicare quality indicators (www.hospitalcompare.hhs.gov) and Healthgrades.com use coded data from patient hospital records to determine quality ratings of hospitals.
• Patients. Patients themselves are beginning to have a greater interest in obtaining, maintaining and understanding their patient records. Although the provider owns the physical or digital record, the patient owns the information in that record and, now under HIPAA, patients have clearly defined rights in what they can demand from the healthcare provider.

Chapter 1 of A Compelling Case for Clinical Documentation: Volume 1 provides almost 20 pages of additional research results and rationale for showcasing the patient record as a key strategic component in any healthcare organization.