Improve patient handover measure true patient complexity with Clinical Documentation Improvement.

 

The primary use of documenting in the medical record is to communicate with other clinicians along the patient continuum. Better documentation ensures there is no ambiguity with the diagnoses or treatment and it facilitates improved communication between clinicians. In May 2017, The Australian Commission on Safety and Quality in Health Care published a review suggesting that poor documentation at transitions of care for patients with complex health care needs is a key safety and quality issue. The report mentioned poor documentation often resulted from missing or mis-communicated information and leads to consequences which included higher readmission rates, failure to follow up after discharge, increased costs and medication errors.

The secondary use of the medical record is for producing clinically coded data that showcases patient complexity. During the coding process, vast amounts of information are translated into International Classification of Diseases (ICD) codes. These codes are instrumental for performance tracking and understanding burden of disease at a national and international level and populate AIHW and state department data. ICD codes are also grouped into Diagnosis Related Groups (DRGs) which calculates reimbursement and measures complexity.

Through the appointment of a Clinical Documentation Improvement (CDI) Specialist, these professionals liaise between clinicians and coders to improve the documentation in the medical record so it can meet both requirements mentioned above.

 Find out more today

The benefits of CDI are far reaching. To have one of our team get in contact with you or a colleague, please complete the form below. By filling the checkbox, you can also receive a copy of our whitepaper  "The Importance of Clinical Documentation Improvement for Australian Hospitals."

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