Volume 2

Best Practices

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Best practices should be aimed at ensuring that your program has a positive impact on your organization and that the processes and results of the clinical documentation program are in regulatory and legal compliance. Federal and state governments, who fund about one-third of healthcare, have significant resources at stake. As such, they will have an interest in ensuring that the money they are paying is for services that were actually performed. Clinical documentation is the basis for payment. Insurers and government entities should feel that your program aims to obtain only the highest quality clinical documentation, which benefits both your organization and the payers. Should questions ever arise, your program methodology is your primary defense that your documentation program is in compliance.

Categories included in this overview chapter include the following:  identifying program “customers”; program “defects”; organizational, medical staff, hospitalists, and ancillary support; tangible tools; software tools; goal setting; tracking, measuring, reporting, monitoring, auditing; and continuing education. This chapter serves as a practical application guideline for all of the training and educational activities addressed in chapters 1 through 9.