The 3 goals of clinical documentation

A lot has been spoken and written about clinical documentation already. In spite of that, many hospitals still struggle in getting the best out of their doctors when it comes to documentation quality. And although we can cite various reasons for this, we can all safely agree that the hospital EMR is the single biggest influence when outcomes to efficiency and quality of documentation — both in terms of compliance as well as the quality of content.

As most of us are aware, enforcing compliance, as well as capturing the best diagnosis-related groups (DRGs), is only one aspect of efficient documentation. And most physicians do an amazing job of using an EMR as a tool for regulatory compliance. Having said that, we seldom use the EMR to our advantage as a great communication tool. Important information is usually lost somewhere in between tons and tons of auto-populated data meant to please the compliance officers and auditors. So, we may be doing great in terms of meeting the billing and coding requirements for a certain level of billing; however, if we fail to communicate what’s truly important, we fail miserably at being good clinicians.

Also, the hospital coding and auditing team will rarely question us about the completeness of our note as long as we have the minimum required elements when it comes to a physical exam or medical decision making and as long as we have captured the acuity by using the right combination of diagnoses. There are multiple reasons for this. Unlike auditing a note for billing accuracy, there is little or no impetus to audit the quality, accuracy, and completeness of notes because there is no financial gain built in by accomplishing such tasks. However, the accuracy and appropriateness of documentation is not only a direct reflection of the quality of our care but will also be our best defense (and sometimes the only defense) against a malpractice situation.

Not only that, but we also know that multiple people in the patient’s care team, including outside parties such as insurances, equipment supply companies, therapists, PCPs, etc., depend solely on our notes to gain information about the patient’s hospitalization. And after reading our note, if the first question that comes to their mind is, “But what is going on with the patient?”, it tells us we are not doing it right.

So while we all may agree that the outwardly apparent goal is to meet all regulatory requirements for compliance, we must never forget the inherent goal of good clinical documentation: accuracy, brevity, and completeness.

Nagendra Gupta is a hospitalist.

Image credit: Shutterstock.com

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