Clinical Documentation Improvement

Clinical Documentation Improvement is mainly aimed at efficiency in billing requirements, insurance and legal requirements. However, with the use of technology, it can now be adapted to make clinical documentation more efficient. Improving patient care is an ongoing challenge to medical and health care professionals. Often, the lack of clear and accurate documentation or medical records of a patient could lead to complications and even to death of the patient. Information technology could provide the required solution to improve patient care by using technology in clinical documentation.

Clinical Documentation Improvement could help enhance the quality of patient care, while reducing the costs involved. It could also help reduce errors in diagnosis, improve the workflow of physicians and nursing staff, and improve availability of patients' medical information to all care providers. Errors in medication can also be reduced, while results of various tests, examinations and other important patient data can be shared in an easier and faster way.

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Clinical Documentation Improvement would have many advantages in improving patient care. A clear indication of the patient's problem and status can be communicated to the various clinicians. The patient's history of disease, treatment and after care can be electronically traced, thereby reducing risks and loss of time. Updating the patient and the physician with the latest outcome of test results, educating the patient on further tests and follow-ups could improve the understanding between the patient and physician. Clinicians can have an integrated approach in the care of the patient by sharing all information across departments.

Reliability and easy availability of medical records results from Clinical Documentation Improvement. People in the medical profession are constantly looking for tools that are rich in content, efficient, and easy to access. The improvement of clinical documentation would help medical professionals in a big way. With increased number of patients needing medical care, administering treatment is a constant challenge. There is the risk of wrong medication due to lack of adequate information. Electronic documentation will ensure safety of the patient, since there would be no chances of misinterpretation of handwritten data. Sharing of data by more than one professional at the same time and providing feedback would be faster. Accessing data remotely would also be possible while the physicians' notes on the patient can be accurately documented, thereby reducing errors.

With the standards for improvement being raised constantly and the compliance of regulations becoming more crucial, Clinical Documentation Improvement would enhance the quality in patient management. With the improvement in quality of care, the scope to implement physicians' recommendations and conducting appropriate tests in a timely manner will also be possible.

clinical documentation improvement provides clinicians with accurate data, allowing them to be more focused in planning the right form of treatment and care. Explaining to the patients and family members would be much easier, giving more time to work together, to achieve the best results.

Clinical Documentation Improvement

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