Three Strategies for Improving Clinical Documentation
Accurate clinical documentation ensures healthcare facilities are reimbursed for the services provided.
Proper clinical documentation is the cornerstone of healthcare revenue integrity. Failing to correctly document a patient’s care can result in claim denials and cost your healthcare facility millions. Below, we’ll explore the importance of clinical documentation and provide strategies to ensure comprehensive and accurate records.
What is Clinical Documentation?
Clinical documentation provides a comprehensive record of a patient's medical history, treatments, diagnostic test results, clinical observations, and other relevant information. This data is then coded and billed, ensuring healthcare facilities receive proper reimbursement for services provided. It is the responsibility of healthcare providers to ensure that this documentation is accurate and complete.
Why is Clinical Documentation Important?
Between 2021 and 2023, the denial rate of inpatient claims increased by 51%, costing hospitals and health systems $1.2 billion in revenue. Hospitals aren’t the only ones negatively impacted by denials. When health plans deny coverage, patients may have to pay some or all costs, and lengthy approval waits can delay their care.
Inaccurate or incomplete documentation is one of the leading causes of clinical denials. Human errors, like missing information, wrong abbreviations, and failing to date entries, are often to blame.
Common clinical documentation mistakes include the following:
Incomplete documentation
Illegible documentation
Inaccurate documentation
Inconsistent documentation
Poor clarity and specificity
Missing or incorrect signatures
Failing to date, time, and sign a medical entry
Wrong Abbreviations
Luckily, 90% of denials are avoidable. Staff training on documentation best practices can help mitigate this issue, saving hospitals and patients money.
Strategies for Improving Clinical Documentation
Establish a Physician Champion
When your healthcare team is busy, proper patient care documentation is likely the last thing on their minds. However, clearly and correctly documenting the full scope of care in a timely, accurate, and legible manner is essential for appropriate reimbursement. Physician champions can help communicate the importance of proper documentation and ensure that it becomes a standard part of the clinical workflow.
Physician Champions are physicians with hospital experience who help to communicate to their peers the importance and impact of their documentation. They understand the challenges of working in healthcare, allowing them to better connect with your team. By leveraging their firsthand knowledge, they can effectively frame and discuss the importance of clinical documentation in a way that resonates with staff.
Provide Physician Training
While physicians receive extensive training on how to practice medicine, they often receive little guidance about how to document patient care accurately. Providing ongoing education on clinical documentation best practices can help bridge this gap, ensuring that physicians are well-equipped to document patient interactions comprehensively.
Training programs should start with a detailed communications plan that outlines best practices in documentation, including objectives, timelines, progress reviews, and desired outcomes. Given physicians’ busy schedules, keep exchanges brief and relevant, using their chart notes for suggestions. Regular updates with data showing program benefits will reinforce the importance of accurate documentation and help integrate best practices into daily routines.
Review Documentation
Many hospitals have a specialized Clinical Documentation Improvement Department (CDI) dedicated to reviewing medical documentation. Regular review of patient records helps identify common omissions and errors, enabling clinicians to receive targeted feedback and education on improving future documentation practices. Review this process to ensure your team is accessing the correct records promptly and effectively communicating with physicians. To prevent overloading healthcare workers with feedback, consolidate communications when possible.
Track Progress
Without tracking the right metrics, you won’t know if your hospital’s clinical documentation improves. To do this, start by defining clear goals and communicating these goals with your team. Once everyone's on board, set and measure specific progress indicators such as DRG mismatch opportunities or decreasing DRG denials.Regularly reviewing these metrics will provide insights into the effectiveness of your documentation efforts and allow for adjustments to continue enhancing performance.
The Eclipse Difference
At Eclipse Insights, we partner with Clinical Documentation Improvement departments, hospital leadership and physician leadership to improve clinical documentation. We have a team of nurses on staff ready to support your physician champions and communicate the importance of clinical documentation. Our partners have experienced increases in medical CMI and CC/MCC capture rates in just six months. Contact us today to learn more about how we can help improve your hospital's clinical documentation.
