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Clinical Documentation Standardization

In some hospitals, clinics and offices, care is still documented utilizing individual unit, department or clinician specific terminology – usually the result of specialty documentation needs of certain units, service lines or physician specialties. A range of terminology may be used and new templates proliferate, creating duplication, making trending and quality reporting difficult, and creating obstacles to evidence-based care. Variance in workflow and templates can even increase time requirements for physician documentation when the impacts are not fully understood. Lack of standardization ultimately impedes efficient EHR data flows, frustrates the goal of a longitudinal view of patient care, and defeats the ability to measure care outcomes and exchange meaningful clinical documents.

The implementation of EHR’s and initiatives like Meaningful Use provide good opportunities to standardize your workflows and clinical documentation while implementing improved Care Planning models.

Jacobus Clinical Informatics experts are experienced in leading EHR’s and understand the constraints and opportunities of each vendor’s software. We are familiar with standardized vocabularies and coding standards such as SNOMED CT®, MEDCIN, LOINC®, MeSH and UMLS, as well as ICD-10, ICD-9, and CPT®. Jacobus can help you drive adoption of language standards such as NANDA, NMDS, and CCC for optimized Plans of Care, Assessments, Flow Sheets, Interventions and improved data collection. We also leverage our HIM and revenue cycle expertise to closely coordinate with existing CDI and ICD-10 initiatives.

Our Clinical Documentation Standardization services include:
  • Assessment of clinical documentation for terminology, compliance, duplication, reporting and risks to patient care
  • Education on standardization opportunities and facilitate the creation of a vision for outcomes that improve communication and patient care
  • Assessment of Care Planning models to identify the best multi-disciplinary approach
  • Simplification of clinician workflows while supporting adherence to standards of care
  • Design of EHR and patient care systems to leverage information integration, automate reporting, and improve data flow to the EHR
  • Monitor and report on quality components for both pre- and post-implementation