Solving the problem of Poor Clinical Documentation


Every aspect of a patient’s interaction with their healthcare provider(s) is documented, from consultation, to treatment, follow-up to billing.  Ensuring quality of care – getting the right treatment to the patient at the right time – relies on accurate clinical documentation.  The documentation tells the patient’s story.  The need, therefore, for the documentation to be accurate and precise simply cannot be overstated. Cause and effect Poor documentation can be easily defined as any instance of reporting that fails to accurately tell the patient’s story, and which, by consequence, fails to result in accurate billing and claims filing. “Clinical documentation is at [...]