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.
Due to our longstanding relationship with the health care industry, 3M has made a serious commitment to comply with all applicable privacy and data protection laws. 3M has processes in place to respect our customer’s privacy and any personal information we collect, regarding a customer or any third party, to ensure it be treated with care, protected, and used lawfully and properly. Learn more