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What Makes Clinical Documentation the Foundation of Patient Health Records?

Posted By Giovanna Stahl

As healthcare research becomes more invested in clinical documentation, it is now further necessary to have accurate clinical documentation and coding. Healthcare facilities require quality metrics that ensure superior patient experience. Therefore, having precise and accurate clinical documentation is a necessity to guarantee high-quality patient care and correct reimbursement. 

 

Guarantee the quality of your clinical documentation by working with professional clinical documentation improvement specialists, such as ECLAT Health Solutions. ECLAT Health Solutions offers clinical documentation improvement services to ensure your patient’s records are complete and accurate. Our professional experts are continuously trained and educated to complement your team in various settings and operational circumstances. Below we explain what clinical documentation is, how it’s used, and why it’s essential. 

Clinical Documentation

In healthcare, over the past 25-30 years the use, need, and importance of clinical documentation and coding has greatly increased. Clinical documentation (CD) is a record detailing a medical treatment, medical trial, or clinical test. These records consist of accurate, timely, specific diagnoses, and procedures that are translated into coded data to represent a patient’s clinical status. The coded data is then used for quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. This is used in diagnoses only to obtain the coverage and medical background and will not persuade or lead to any particular diagnosis. Clinical documentation is at the core of every patient encounter and has become the foundation of patient health records. 

How Are The Records Used?

Clinical documentation is used to facilitate inter-provider communication, allow evidence-based healthcare systems to automate decisions, and create patient registry functions so public health agencies can manage and research large patient populations more efficiently. Clinical documentation is also used to maintain healthcare information from all sources for an individual patient and for evaluating claims. Additionally, healthcare research has a significant dependence on clinical documentation and coding. This research includes information on social factors, financing systems, organizational structures and processes, health technologies, clinical data, and personal behaviors. All of this information is gathered and transcribed as data and used in clinical documentation.  

Effective & Accurate Clinical Document Improvement Solutions from ECLAT Health Solutions

Clinical documentation has a direct impact on patient care by providing information to all members of the care team, as well as those who may treat the patient later. There are many rules and guidelines for clinical documentation and coding that must be followed to ensure a strong and accurate healthcare foundation. Therefore, you should refer to a professional clinical documentation improvement specialist to ensure the quality of your patient records and the overall healthcare experience. 

 

At ECLAT Health Solutions, we adhere to the ethical standards and foundational guidelines of the medical coding industry. Our highly experienced staff are both trained and certified in medical coding and billing. We set ourselves apart by performing a thorough and efficient investigation on any problematic claim, working until the issue is identified and fixed promptly.


Contact us by filling out our form for a free consultation with our billing experts and professional coders. 

Tags: clinical documentation improvement

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