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Accurate clinical documentation of records directly impacts patient safety

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Properly done clinical documentation shows a true picture of a patient’s condition, and therefore increases safety.

Accurate clinical documentation and data have a direct impact on patient safety, said a speaker on the last day of the three-day Patient Safety Virtual 2021 conference that started on Thursday.

Talking at the session on “Supporting patient safety through high quality clinical documentation” on November 6, Tammy Combs, Trainer and Director at AHIMA CDI and Clinical Foundations said: “We often think about the direct impact clinical documentation has on patient safety but it is important to understand how it works.

Clinical Documentation Integrity (CDI) teams document in real case scenarios and we have several examples of the impact that documentation integrity has on patient safety itself.”

CDI programmes that healthcare organisations can initiate are a representation of the patient’s clinical status.

“These CDI programmes include what happens during the patient’s stay, how sick the patient was, the diagnosis, what was the treatment plan - all of which is recognised through clinical documentation.”

CDI facilities also make sure that the data is an accurate representation by reviewing the health records and also ensure that it meets CDI standards that they are validating so as to translate that information into appropriate coded data.

Combs said that it was important to review data thoroughly. “We look at data for many different reasons. There are many avenues through which patient data is reviewed as it impacts reimbursement for many organisations. The review also shows the quality of care that is provided, supports research as well among many other utilisations of that coded information through data analysis,” she added.

Combs also said: “It is important to think of CDI being at the core of the patient record because it is telling the patient’s story and we want to make sure that we are telling an accurate story; for that we have to make sure that the documentation is meaningful, timely, accurate and also reflects the scope of services that were provided.”

The same characteristics can be applied to different settings whenever medical records are reviewed which makes it the foundation of integrity that is a key component of documentation. 

“We know that having high quality documentation can have an impact for the organisation, for the patient and for the provider because it is telling the true story of what occurred.”

But how does this documentation impact patient safety? 

Documentation that is complete and consistent, timely and clear, precise and legible and reliable will show the true picture of a patient’s health condition.

“When we look for complete documentation for a patient’s medical records, we are looking for maximum and thorough content and relevant information. Documentation should also be consistent and not contradictory.

For example, there should be no contradictory diagnosis if we are looking at a health record and there are several providers looking after the patient,” added Combs.

Documentation should also be timely and prepared as close as possible to the point of care. It should also be clear and concise with a thorough description of patient’s picture.

“It should also be precise, accurate, exact and strictly defined as well as legible in a language that is easy to decipher and comprehend. It should also be reliable documentation that is trustworthy and safe.”

CDI impacts patient safety as it supports medical decision making, helps identify missing or incomplete information, recognises potential safety concerns in patient care, and also validates that documentation has been added to patient care.

It is important to have CDI teams in place at the healthcare facility to ensure patient safety at your organisation, added Combs.

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