As one of the most important phases of the health care industry, clinical documentation should be maintained by implementing improvement programs. Medical records can either make or break a hospital’s financial and clinical capabilities. It is very important to implement the most appropriate clinical documentation improvement program (CDIP). As always, the very first step is to understand how a CDIP works so that the objectives and goals can be set. To understand the process means knowing the purposes and the possible end results. Inadequate knowledge can hinder successful implementation which also leads to wasted time and resources. On the other hand, proper awareness leads to more convenient execution and better results.
So what are the common purposes of a clinical documentation improvement program?
- Improvement programs are conducted for the purpose of highlighting the pivotal roles of HIM (Health Information Management) and medical records department. In the process, the medical professionals in charge of the improvement program will put enough focus on the storage, compilation, and management of medical records.
- A CDIP is implemented to help a medical institution become more productive while eliminating the common disadvantages of clinical documentation. Also, daily operations will be protected from a wide variety of legal risks and issues brought by improper record keeping.
- A clinical documentation improvement program is designed to help a medical institution prepare for upcoming revisions in clinical documentation and coding. For instance, the upcoming ICD-10 which is the tenth revision for International Classification of Diseases will be implemented by 2013. Without adequate organization of the current system being employed, it becomes harder to adjust to the new regulations. A CDIP help identify the areas that require improvements and corresponding solutions for potential points of failures.
- A CDIP promotes the real purposes of medical records which are expected to be accurate, complete, secured, legal, consistent, and accessible. This means that important medical records and documents should be able to support high quality medical services by providing a complete and reliable view of a patient’s medical history.
- CDIP also promotes productivity with the use of modern tools, applications and solutions that ensure compliance and quality for medical record keeping.
There are a lot issues that hinder the real purposes of a clinical documentation improvement program. Unless physicians realize these important purposes, a hospital could not enjoy the full benefits of effective clinical documentation. To learn more, visit clinical documentation improvement forum.