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Key strategies for improving clinical documentation in 2023


Enhancing medical records helps cut expenses and boosts overall output.

Clinical documentation is essentially a collection of records and information relating to someone's medical care. Symptoms, diagnoses, drugs, procedures, tests, and examinations may all be included in this, among other things. Gathering and keeping track of every one of these records gives healthcare professionals a better understanding of their patient's health status, allowing for more educated decisions and eventually better clinical outcomes (1).

It is crucial to continually enhance healthcare documentation since timely and accurate documentation is essential to a healthcare organization's performance. Enhancing medical records helps cut expenses and boosts overall output.

A medical record improvement team is used by many companies because of the significant time savings that could be realized. You must look at the areas that can undermine excellent documentation to enhance healthcare documentation and reporting for your firm (2).

What is clinical documentation improvement?

The practice of examining medical record documentation for correctness and completeness is known as clinical documentation improvement (CDI). The CDI comprises an assessment of the illness process, diagnostic results, and any potential gaps in the documentation.

A CDI specialist frequently has experience in both healthcare and medical coding. The goal of CDI programs is to reduce the discrepancy between correct coding and clinical documentation.

The term "clinical documentation" in the context of CDI typically refers to the records by a provider or clinical member of the staff who is in charge of the patient's care during a physical visit, although reports from tests conducted, diagnostic procedures, and specialist consultations may also be included in a patient's medical record (6).

Characteristics of good clinical documentation

The following are some of the characteristics of good clinical documentation:

  • Clarity
  • Precision
  • Consistency
  • Timely
  • Measurable (4).

How Can Clinical Documentation Be Improved?

The following are some of the ways clinical documentation can be improved in 2023:

Team education

Your staff could require further training if productivity declines are caused by inaccurate, incomplete, or illogical documentation. When it comes to documentation, it's crucial to ensure that everyone in your business is on the same page. For certain team members, this may require relearning the fundamentals.

Results from testing communication and reporting should serve as the basis for educational decisions. The main purpose of education and retraining should be to clear up any misunderstandings or uncertainty in reporting.

Assess communication

You must make sure that your organization's CDI staff, physicians, and coders are all in good communication with one another. If problems keep coming up, they must be fixed.

Reduce shorthand

Finding areas of miscommunication among these groups is one of the main goals of communication assessment. This misunderstanding could result from using illegible or unfamiliar shorthand.

Because shorthand only functions if all parties understand and agree upon its meaning, it may result in misunderstanding or inaccuracy. Clarifying shorthand-written words or avoiding them entirely are both important parts of resolving the problem (2).

Collecting patient information accurately

You must gather complete demographic and insurance data during the patient screening procedure. A solid claims process is built on the collection of reliable patient data.

It is crucial to get a duplicate of the patient's insurance card. Asking for a duplicate of the health insurance card at each visit and comparing it to the information in your system is best practice when dealing with repeat customers. The offices that don't use this procedure frequently have their claims denied because their patient demographic data is incorrect.

If your clinic notices a sudden increase in denials or a pattern of consistent denials, there may be a problem with the intake procedures. After several claim denials, giving your front desk employees feedback enables them to identify the underlying cause, make the necessary corrections, and gather the data essential for future clean claims (3).

Importance of CDI in patient care

An effectively practiced CDI has the following importance in the health care of a patient:

Legal situations

In some circumstances, clinical notes may be utilized as legal documentation. Even though practitioners should take every precaution to avoid becoming the subject of a negligence or clinical negligence lawsuit, they must have the necessary paperwork in place just in case.

Patient satisfaction

The healthcare sector is transitioning to a consumer-based care model where patient needs and wishes are prioritized more frequently. An emphasis on patient pleasure is among the core ideas of consumer-based care.

A growing number of patients in the current healthcare era demand as much openness as possible in the way their treatments are carried out. With an excellent CDI, patient satisfaction can be achieved in this regard (1).

Revenue cycle management (RCM)

RCM (Revenue Cycle Management) can be compared to a mode of transportation that gets a company where it needs to go from one location. The systems in place to support the transport must be precise and planned for it to take place smoothly and be operationally sound. The likelihood of the vehicle arriving at the location with a defective tire would make failure more likely.

The crucial data must be precisely captured for claim production, claim submission, and complete payment recompense for this operation and process to succeed. Anything less than these two operational requirements cooperating will put the firm at risk of denials (5).


  1. https://www.carepatron.com/blog/the-ultimate-guide-to-clinical-documentation
  2. https://www.dolbeyspeech.com/blog/tips-to-improve-healthcare-documentation/
  3. https://larsenbilling.com/resources/reduce-denied-claims/
  4. https://practolytics.com/blog/importance-of-clinical-documentation-how-its-impact-your-practices-revenue/#:~:text=An%20adequately%20documented%20clinical%20record,swift%20payments%2C%20and%20timely%20reimbursement.
  5. https://yes-himconsulting.com/clinical-documentation-integrity-significance-in-revenue-cycle-management-healthcare/
  6. https://www.aapc.com/clinical-documentation-improvement/

Hariharasudan is the CEO & founder of 24/7 Medical Billing Services, a revenue cycle management company that helps practices boost their practice performance & increase their revenue through custom billing solutions. Drop an Email to Hari here to know more

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