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April 23, 2019

What's Your Position on the Primary Purpose of Clinical Documentation?

 

Effective physician communication of patient care serves a wide array of different purposes in the overall scheme of healthcare delivery, the most important consisting of facilitating fully informed coordinated patient focused quality outcomes-based cost-effective care for the patient. The American College of Physicians sums it up nicely when it comes to the primary purpose of clinical documentation in an article published in the Annals of Internal Medicine position paper titled Clinical Documentation in the 21st Century: Executive Summary of Policy Position Paper:

 

  • The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up.
     

  • The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
     

  • The clinical record should include the patient's story in as much detail as is required to retell the story.

 

As CDI specialists, what should our focus be in regards to chart review and enhancing the value and completeness of the physician documentation? First and foremost, we should recognize and treat our duties and responsibilities as a clinical documentation integrity specialists in the fashion of “facilitators in communication of patient care.” This facilitation entails incorporating a holistic approach to reviewing