Errors in clinical paperwork can have disastrous results. They can cause damage to patients and lost revenue if the insurance provider rejects a claim. If your facility is experiencing issues with the quality of medical records, you may benefit from a clinical documentation improvement (CDI) program.
What a Clinical Documentation Improvement Program Can Do for Your Facility
Quality documentation can improve the quality of care your clients receive, increase reimbursements, and provide you with the accurate data you need to run your practice. Weak documentation can lead to problems throughout your business, including dissatisfaction from patients and low reimbursements.
To improve your documentation, you first need to pinpoint the problems. Are there inconsistencies in reporting? Is there information left out? You need to know what is wrong with your processes so you can build a plan to correct it. Often those closest to the situation have trouble recognizing what is wrong with the existing system. Having an outside consulting team come in and work through the documentation allows you to create a new standard that works for your facility.
In addition to looking at the processes used to put together documentation, the consultants will look at the tools you are using to see if they are the best ones for your practice. Streamlining processes with solutions crafted for your practice reduces errors and inaccuracies.
Much of healthcare today rely on coded data. This data is used to provide information to the patient’s care team, is used for billing, and to provide a record of everything that goes on during each visit. It is important that individuals who input and utilize the data have specialized training and an understanding of proper coding protocols, security, and privacy. Attention to detail and respect for the importance of the documentation process is also necessary.
If your practice is struggling with their documentation, a clinical documentation improvement (CDI) program may be necessary to get back on track. Working with a top healthcare business processing outsourcing company, such as GeBBS Healthcare Solutions, can provide you with the process improvement and training your facility needs.
