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6 Clinical Documentation Best Practices

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Bobbie Byrd

Clinical documentation forms the foundation of a patient's medical record, an enduring document that details the care a patient receives. Within each patient's record, healthcare providers document critical information, including changes in the individual's medical condition, fluctuation of outcomes as well as the evolution of the care provided to meet the needs presented by the patient's diagnosis. As such, clinical documentation serves as a reference for a patient's treatment plan and provides data for quality assurance monitoring. 

Our Advice - How To’s, Tips and Tricks For Clinical Documentation

A patient's healthcare record is a legal document that substantiates the medical necessity of healthcare services a patient receives. Also, the healthcare record is the primary method of communication among healthcare providers who care for a patient. Beyond its clinical applications, a healthcare record includes the supporting documentation needed for service reimbursement. 

For these reasons, it is imperative that clinical documentation adheres to secure and steadfast medical record keeping. Let's take a look at six of the current best practices for documenting a patient's clinical care.

1. Convey The Entire Patient Experience

Medical documentation should tell the patient's story, not just provide the data gained from laboratory testing, treatments and evaluations. As a result, a patient's record should communicate the patient's past and present health information as well as include any medical treatment received from other clinicians. Additionally, an evaluation of the impact of treatment options should be included and should convey the physician's thought processes in determining diagnosis or best treatment recommendations. 

2. Use An Electronic Medical Record (EMR) Or Electronic Health Record (EHR) System

The use of electronic records is highly recommended in the high-tech world of the 21st century.  With an EMR/EHR system that incorporates multiple aspects of practice management with meticulous documentation features, practices can streamline all the prongs of healthcare engagement, reporting and billing. This approach empowers providers to facilitate smooth, seamless communication between various healthcare disciplines. Today, many healthcare organizations are turning to an all-inclusive system that combines EMR/EHR documentation features with telehealth capabilities and portals for direct, interactive patient engagement.

3. Train Staff In The Implementation Of Clinical Guidelines

The effectiveness of an electronic documentation system is only as good as the training of the team who use it. Various training strategies have proven effective, such as creating groups of "super users" who take advantage of vendor training and then provide internal instruction to clinicians or office staff. 

4. Document Current Patient Behavioral Trends and Intervention Outcomes

The medical record must include information on the patient's progress as related to the treatment plan. If the patient is noncompliant with treatment measures, such as refusal to take medications or non-participation in physical therapy, this should be included in the record and updated as necessary. In addition, records should also include evidence that there was ongoing monitoring of the patient's clinical condition (with improvement or lack thereof) documented with each visit.

5. Leverage Data To Optimize Healthcare Delivery

Utilizing technology that allows feature customization can empower the use of business intelligence (BI) and analytics, help boost collaboration between users in addition to facilitating the sharing of clinical data. Custom configured systems provide your practice with increased documentation flexibility as well as enhanced data analysis formats such as custom tables, charts and diagrams. Furthermore, low code or no code software solutions offer fast, reliable, user-friendly interfaces that ultimately streamline patient visits, reduce staff overhead and improve clinical documentation efficiencies.                                                                                          

6. Employ User-Friendly Dashboards To Reduce Documentation Time

Effective, thorough documentation takes time. The general rule of thumb for all healthcare documentation is this: if it isn't written down or included electronically in the record, it did not happen. That's why implementing an intuitive user interface with a low learning curve can minimize the time team members spend documenting evaluations, giving them more time to focus on making patient visits more engaging.

Confidentiality Is Critical

A patient's clinical records, including identifying information, such as name, address and phone numbers, along with data on a patient's diagnosis, prognosis or treatment fall under the umbrella of patient confidentiality. Consequently, anyone who has access to these records must protect all patients' personal health information since the Health Insurance Portability and Accountability Act (HIPAA) governs what information can be released, who may receive information and whether direct patient consent is required or not. While the patient has the legal right to access their personal medical records, healthcare teams should be aware of all applicable HIPAA laws and exercise caution if anyone else wants to look at a patient's record. 

All in all: keep it accurate, keep it relevant, keep it objective and keep it confidential. If you want to learn more about Raintree’s clinical documentation, explore more of our blogs including: 


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