Clinical Documentation
December 28, 2021

10 Ways To Make Your Clinical Documentation Better Starting Now

10 Ways To Make Your Clinical Documentation Better Starting Now

What is clinical documentation?

Clinical documentation refers to the recording of details pertaining to encounters with patients. Clinical documentation is an integral aspect of working as a healthcare professional, regardless of what specific field you work in. Because these documents have such a significant role to play in various processes, looking for ways to improve your note-taking is always a good idea. Not only are clinical notes required for insurance contexts, but they have been shown to elevate the patient quality of care and improve clinical outcomes. It is understandable that clinicians can find it difficult to keep up with the amount of note-taking that is required of them, whilst also ensuring their documentation is consistently accurate. One study suggested that around 70% of patient records contain false information, an alarming statistic considering how important documentation is. Ultimately, regardless of whether you are just starting your career or are a seasoned professional, clinical documentation improvement is always possible. 

clinical documentation


Importance of clinical documentation in any healthcare setting

Before you can effectively begin improving your methods of clinical documentation, it is critical to understand exactly why they are so important. Effective clinical notes will have various advantages for your healthcare practice, including:

  • Productivity: When operating a healthcare business, it is always in your best interest to look at ways to improve productivity. An unproductive practice will lead to clinicians spending a lot of their time on administrative tasks, which can reduce the number of patients that are being seen. Efficient clinical documentation will save a lot of time, as physicians don’t have to search for notes, and the actual writing process is significantly reduced.
  • Patient satisfaction: As the healthcare industry shifts to value-based care, it is important for practices to implement new systems aimed at achieving patient satisfaction. Effective clinical documentation can help with this, as patients can access their medical records and the process of delivering care is made more transparent. 
  • Progress: As I’m sure you know, one of the sole reasons that clinical documentation is required is because it tracks the progress of your clients. Effective clinical documentation will lead to more accurate progress monitoring, allowing businesses to improve clinical outcomes and continuity of care. 
Importance of clinical documentation

10 effective tips to make your clinical documentation better

CDI (clinical documentation improvement) programs are being implemented into hospitals and private practices at an increased rate, reflecting the growing challenges associated with receiving accurate reimbursement. We have collated some of the key strategies that often accompany these programs to help you ensure your clinical documentation is as effective as possible:

  • Data: In order to improve clinical documentation, you must first identify the specific aspects that require improvement. By observing the documentation through data analysis, you will be able to pick up on the inefficiencies. For example, you might find that some notes have discrepancies, missing information, or coding deficiencies. Data analysis will allow you to target these specific areas and ultimately improve your documentation.
  • Quality over quantity: It is important that your clinical documentation is thorough and accurate, but this doesn’t necessarily mean it has to be lengthy. Progress notes should never exceed two pages in length, and you should avoid vague language and lengthy sentences. 
  • Timely: There are two reasons why clinical documentation needs to be completed in a timely manner. Firstly, these notes need to be accurate, and the best way to ensure accuracy is by writing them whilst information is fresh in your mind. Secondly, all forms of clinical documentation are dated and signed, and it will work in your favor if you consistently write your documentation in a timely manner.
  • Software: As technology continuously develops, we are seeing an increase in the number of healthcare practices implementing these systems into their business. Software allows for effective practice management by providing clinicians with a secure storage location, and various tools that streamline the clinical documentation process.
  • Templates: Various documentation templates are available to physicians, and you shouldn’t be afraid to use these. Regardless of what specific format you prefer for your documentation, these templates will help you increase consistency and ensure you don’t leave out any important information. 
  • Central database: Regardless of whether you decide to implement an EMR into your practice, all of your clinical documentation should be stored on a central database. This means that clinicians won’t have to waste their time searching for documents, and they are accessible 24/7.
  • Workflow: CDI programs are likely the best way to improve the clinical documentation of your practice. If you incorporate one of these programs into your clinical workflow, then physicians will be able to efficiently improve their documentation without it interrupting their regular schedule.
  • Keep up to date with guidelines: As the guidelines for medical billing and documentation frequently change, it can be difficult to stay up to date. However, ensuring you are aware of updated guidelines will allow you to reduce the number of reimbursement rejections and denials your practice receives, allowing you to get paid on time.
  • Educate: This might seem obvious, but it is critically important that your physicians are aware of the reasons why CDI programs are important. If they don’t understand the uses of clinical documentation, then it will be difficult for them to improve theirs.
  • Continuous progress and performance monitoring: Lastly, to ensure that any improvements made to clinical documentation methods are long-lasting, you should monitor progress and performance continuously. This will ensure physicians maintain accountability, whilst also giving them long-term support.
effective tips to make your clinical documentation better

Examples of excellent documentation

Clinical documentation will look slightly different, depending on whether you are a nurse, general practitioner, psychologist, or therapist. Nevertheless, if you employ the above strategies in your work, you are guaranteed to increase the accuracy of your documentation. Implementing sophisticated healthcare software into your practice will undoubtedly provide you with the resources required to elevate your clinical documentation. These systems should have a unified workflow, note templates, and cloud-based storage capabilities to allow you to produce consistently excellent documents. 

Example of excellent documentation

Conclusion

The importance of clinical documentation means that every healthcare practice should constantly be finding ways they can improve their notes. Although how you choose to construct your documentation is largely dependent on personal preferences and the field of healthcare you work in, we recommend implementing electronic software that can streamline this process. Carepatron offers a fully integrated, HIPAA-compliant platform that is guaranteed to improve your clinical documentation. It is mobile-friendly and comes with various note templates, medical billing features, and cloud-based storage capabilities. Your notes will be easier to write and easier to store, granting both patients and physicians 24/7 access, regardless of where they are in the world.

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