Volume 2

Clinical Documentation Management: A Dynamic Process

Previous Chapter

We exist in a constantly changing environment. And, healthcare may be impacted by more changes than any other industry. As a result, it is important to ensure that your clinical documentation program is a dynamic process. In this chapter, we address specific assessment methodologies, outside resources, internal activities, and goal setting that ensure your program and the physicians and staff supporting it are on the cutting edge in the industry. If you have had a program in place for some time, this chapter provides some suggestions on how to breathe new life into it. If you have a new program, this chapter will provide you guidance on how to structure your program now to ensure a growing, dynamic function that continues to contribute to your organization’s vision and mission.

This chapter demonstrates how a clinical documentation program can be both standardized and receptive to program feedback and changes in the industry. Important components include continuous communication, standardization, and the training-feedback loop. The importance of physician and employee engagement for any change management process, but particularly for a clinical documentation program implementation is described.