Volume 2

Teaching and the Theory of High Quality Clinical Documentation

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The theory of high quality clinical documentation (HQCD) is derived from evidence-based medicine as well as the regulatory and legal requirements discussed in prior chapters. The theory states that if the seven criteria of high quality clinical documentation are consistently applied to clinical documentation, then clinical documentation quality will be high and the accuracy of care, quality indicators, reimbursement, healthcare planning, and research (the activities that clinical documentation impacts) will be improved.

Evidence-based medicine entails practicing medicine using only the best scientific data available. Volumes 1 and 2 of this book present all of the scientific data available from peer reviewed journals that illustrate and attest to the current problems with quality of clinical documentation and the potential for a self-efficacy based intervention to improve quality. In Evidence-Based to Value-Based Medicine, the authors argue that evidence-based medical (EBM) data enable clinicians to deliver higher quality care. The authors further state that learning about EBM improves the efficacy, or confidence, with which physicians gather and process new information. However, confidence will only increase if physicians can trust the EBM data. And data can only be trusted if it is derived from high quality clinical documentation.

This chapter describes criteria for HQCD in great detail, providing documentation examples of when the criteria have been met and when it is deficient. Slides used during the training session are included in the chapter.