Clinical Documentation Improvement Programs

Clinical documentation improvement programs help hospitals and other medical institutions in documenting medical records completely and accurately. Clinical documentation is of utmost importance to hospitals in the wake of new federal and state regulations that weigh healthcare payment against quality outcomes. Accuracy of the data on the severity of illness and risk of mortality are some points that affect the quality outcomes of a medical institution that many insurance companies take into consideration when calculating payments to their customers.

Clinical documentation improvement programs collect patient’s data pertaining to the entire period of hospitalization including health condition at the time of admission, diagnostics, laboratory procedures and equipments used and medicines administered. The data also includes the patient’s medical history and any secondary diagnosis made. Since the data is collected in its entirety, it facilitates coding and improves the quality of health-care reports. These programs also educate and train the health-care team regarding documentation guidelines. The crux of the program is to ensure that patient care is consistent and complete and a patient’s entire medical history is available at a central location that is accessible to authorized health care professionals anywhere and at all times.

A number of Clinical documentation improvement programs have been developed by various service providers such as those developed by 3M, HP3 and Wishard. 3M has built CDIP software that helps in accurately grouping hospital cases and correctly assessing the severity of illness and risk of mortality. The software also helps the health-care team to quickly identify the health-care plan required by a patient and determines the length of hospital stay required. The CDIP developed by HP3 ensures that the hospital’s revenue cycle is accurate and correctly reflects a patient’s acuity levels. HP3 has also built software programs that train physicians and other clinical staff in documentation, summary reports, and financial results. The CDIP developed by Wishard focuses on securing medical documentation that creates consistency between the reports on the severity of a patient’s illness as provided by the hospital and as reported by the physicians.

In other words, clinical documentation improvement programs help to accurately reflect healthcare services provided by doctors, nurses, physiotherapists and dieticians from the time of diagnosis till the recovery or discharge of the patient. This makes the clinicians more responsible for their actions and also ensures that the patient is provided with an accurate diagnosis and complete treatment without overlooking any minute information from his or her medical history.