The medical record is the cornerstone of information within a healthcare organization. Implicit, ambiguous or missing documentation paints an obscure picture of a patient’s severity of illness, intensity of service, medical necessity, and justification of resources consumed. But, most importantly the quality of care rendered is interpreted exclusively by the documentation within the medical record.
Clinical documentation is the key to the exchange of critical information with all members of the clinical team. It is paramount to the continuity of care describing clinical conditions to assist in developing and executing a plan of care, helps avoid negative consequences, such as adverse medication events and provides data for clinical research.
Explicit documentation illustrates that the service was medically necessary to justify payment at the level billed, provides diagnosis and procedure information to determine the coding that leads to the correct prospective payment and drives the quality of data within the health care system.
Every word documented provides a pixel in the clinical picture of patient care and contributes to its clarity. Conversely, ambiguous, implicit and missing documentation blurs and distorts the image. Effective documentation communicates the actual quality of care delivered for all to see, clearly.
IS YOUR CLINICAL PICTURE CLEAR OR PIXELATED?
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