How to overcome the risks of poor document management workflow?

Medical documentation is digital or analog records detailing a patient’s visit to the clinic. It consists of the medical treatment the patient has received, the timing of the patient’s check-in and check-out, and specific diagnoses and procedures encrypted into the ICD and CPT codes to represent a patient’s clinical status. Its accuracy is directly related to the improved quality and patient safety outcomes and increased reimbursement; it helps to conduct the quality audit of the medical services offered and investigate any severe incidents in the patient’s care, and as far as the timely reimbursement is concerned accuracy is the most prior legislative requirement if there is a lack of information regarding patient’s test it can cause unnecessary delays and possibly even denial of reimbursements. In these circumstances, we are here to demonstrate the best practices to overcome the risks of poor document management workflow in healthcare.

What constitutes poor medical record documentation?

In general, poor documentation lacks clarity, specificity, or completeness, probably because of the inaccurate diagnosis and procedure code assignment. Per the HCPRO demonstration, incomplete medical documentation defines that insufficient medical care was provided, which does not comply with the regulatory regulations and is used to support allegations of negligence and fraud.Slot Depo 5k

If the clinical documentation consists of billing and coding flaws, it fails to convey the patient’s problem concisely, and the logic to address that problem will put the patient’s safety at risk, and efforts also get weak to estimate the quality of the rendered care. Furthermore, it will also cause medical providers to face a loss in practice revenue and unnecessary, expensive diagnostic studies, face legislative penalties, and lose their medical licenses.

Factors that play a role in poor patient documentation

Lack Of Education:
Most CDI experts put the insufficient provider education factor at the top of the list, which is a fundamental reason for patient documentation failure. Physicians are extremely busy providing medical care to patients; therefore, they lack an understanding of the specific information that needs to be included for coding purposes. A lot of information needs to be documented. Still, due to a lack of education, there is a shortfall in the clarity of their handwriting that is unable to define the highest level of specificity.

Lack Of Time:
Providers cannot document a patient’s visit because they have a flow of patients in their clinics, and it is their prior responsibility to spend most of the time providing medical care to their patients. In this way, patient documentation becomes their secondary priority. Documentation problems can be solved if physicians spend more time creating the patient’s document, but the bitter fact is there is a lack of motivation for clinicians to provide remarkable documentation. EHR Complications: Although EHR has improved the readability concerns of the documentation, it has also led to significant concerns regarding the manual work of copy and pasting within medical records. According to Dr. Dan Siegel, EHR can improve documentation in the long term if certain boxes are checked first. Most significantly, he says software vendors must work closely with users, both clinicians, and coders, to make meaningful adjustments.