Clinical Documentation Integrity and What’s in Store for the Future

Clinical documentation is probably not high on your list of riveting healthcare topics, but it is at the heart of everything related to patient care and the financial health of your practice. Whether you’re a provider, administrator, coder, or payer, documentation is a key component of your work. It helps to ensure healthy patient outcomes, timely payer reimbursements, and regulatory compliance. With such broad effects, it is no wonder clinical documentation is subject to constant scrutiny and process improvements.

Clinical documentation basics

Clinical documentation consists of all the documents and information related to each individual patient’s encounters with a healthcare facility. Documentation ensures all members of the care team receive current and correct information about their patients. Accurate and complete information is critical to patient health and safety. Clinical documentation assists medical staff in their efforts to provide the best possible care. It also facilitates payer reimbursement and lowers the risk of claim denial.

The importance of clinical document integrity

Clinical documentation integrity (CDI) — also known as clinical documentation improvement — is designed to ensure consistency, completeness, and accuracy of health records for improved data quality, patient outcomes, and claim reimbursement.

The American Health Information Management Association (AHIMA) explains, “Successful clinical documentation integrity programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.”

Clinical documentation is vital to all aspects of the healthcare industry. Because emphasis on the integrity of documentation is high-priority, providers and their staff should receive regular training on new and best practices.

The future of CDI

With increasing focus on quality control in clinical documentation, accountability is a growing concern. Widespread use of electronic health records (EHR) and automation technologies means CDI will also come to rely on technology. Digital technologies and EHR make it easier to create, edit, and code documentation. It also puts additional burden on providers who complain of burnout from the number of clicks required to complete charge capture. But advanced technologies, such as front-end speech recognition, computer assisted physician documentation, and computer assisted coding alleviate much of the burden.

As CDI programs improve, there will be less need for coding audits. Conversely, as coding programs get more accurate and efficient, CDI programs will become less necessary.

Contact HRG to learn more about clinical documentation, CDI, and the importance of complete and accurate records.