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HIT Leaders & News Feature: Comprehensive clinical documentation done right

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10 Must Do’s for Success Under Value-Based Models

HIT Leaders & News recently published an article by Paulette Schroeder, Senior Managing Director of Clinical Screen Shot 2016-07-08 at 10.17.41 AMInformatics at Jacobus Consulting titled, “Comprehensive clinical documentation done right.” In the article, Schroeder argues that in the changing healthcare environment, the mere effort to provide great care is likely wasted if it isn’t documented correctly. Below is a summary of the 10 important factors that provider organizations should consider for success. Read the full version here.


  1. Complete, comprehensive data is a non-negotiable imperative. The combination of narrative and discrete clinical information helps to tell the complete patient “story” and provides organizations with the foundation needed to move toward enhanced care experiences, improved outcomes and reduced costs associated with the triple aim.”
  2. The value of discrete data. Discrete data can help develop the metrics that are needed for clinical care quality improvement efforts both on the patient and population level. In addition, when electronic medical records include prompts that call for discrete data, clinicians are more likely to document the quality of care they deliver.”
  3. The importance of narrative data. Adding narrative clinical information into the mix makes it possible to develop the foundation needed to describe the state of the health of patients. Laying this groundwork is becoming increasingly important under emerging value-based models. Currently, such documentation is most critical in the Medicare Advantage environment as there is a direct revenue consequence associated with the initiation of Hierarchical Clinical Categories (HCCs).”
  4.  The need to substantiate complexity. Under value-based care, reimbursement improves as the complexity of the patient increases. Properly executed digital clinical documentation supports this risk adjustment and stratification.”
  5. Why it’s important to leverage templates for common diagnoses. Organizational leaders should determine where it is most beneficial to collect discrete data via their EHRs based on unique Physician Specialty. Medical practices need to create templates that collect the data that affects a significant portion of their patient population. By doing so, they can efficiently and cost effectively develop templates and train physicians, staff members and coders to collect the information that will have the most significant impact on quality and reimbursement at their practices. This data, in turn, can be leveraged to monitor quality, receive optimal reimbursement and report outcomes.”
  6. Why and when standardization can be a good thing. It’s important for caregivers to understand that standardization helps to improve quality and defend reimbursement, as it ensures comprehensive care delivery, accountability, and on-time payments. If templates call for documentation, it is more likely that physicians will provide that documentation and qualify for the optimal and defensible reimbursement.”
  7. The consequences associated with poor workflow. Provider organizations need to ensure that documentation does not impede clinical workflow… Organizations need to aim to develop templates and provide training that makes it possible to actually improve clinical workflow.”
  8. The importance of right person, right time – right communication. It’s an absolute imperative to develop templates that enable the right clinical professional to document the right information… The templates should enable communication between the various caregivers, ensuring that the right information get to the right people at the right time.”
  9. Why everyone needs to have their say. Involving physicians and other staff members in the development of documentation templates often helps to improve how quickly and adeptly clinicians adapt to the new documentation…. It’s also important to look at workflow in terms of industry best practices and regulatory requirements.”
  10. The dangers associated with data cloning. Medical groups need to specifically be careful about “whole- note cloning,” the practice of copying and pasting previous notes into the EMR in an effort to speed documentation. While this documentation technique can increase efficiency, it also can threaten the integrity of records. The practice can result in inaccurate documentation… Medical practices need to make sure that they are always documenting care so that it reflects the particulars of the patient’s illness, with events sequenced chronologically, along with appropriately inserted clinical commentary and discussion of treatments.

These ten factors can help healthcare organizations become more successful– both clinically and financially – in their efforts to develop and implement comprehensive clinical documentation that will support improved care under value-based care models. Read the full article or learn more about Jacobus Consulting’s Clinical Documentation Services. To connect with Paulette Schroeder, contact us.