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Putting a Proper Perspective on "Proper" Documentation

April 1, 2018




Proper Documentation is Critical to Our Modern Healthcare System


Proper documentation is indeed critical to our modern healthcare system. The accuracy and completeness of clinical documentation that translates into ICD-10 codes utilized in many distinct roles including quality and outcomes reporting, measures of efficiencies and effectiveness of care, and calculation and determination of value is critical to the entire healthcare delivery model. Clinical documentation improvement programs are purported to “improve” the quality and effectiveness of physician documentation through capture of clinical specificity in diagnoses as well as appropriate capture and reporting of healthcare associated conditions and patient safety indicators. The term “proper documentation” can be defined in a myriad of ways ranging from focus upon diagnoses specificity to the preferred more meaningful approach of communication of the entire picture of patient care longitudinally from initial patient presentation to discharge.


Allen Frady in his article published in in the Journal of AHIMA blog March 29, 2018 titled Proper Documentation is Critical to Our Modern Healthcare System (Proper Documentation Critical) makes several notable points related to the concept of proper documentation. All his points are valid and relevant, raising a few k