Allotting the Right Attention on Clinical Documentation

The most important concern of the several health care institutions these days is certainly Clinical Documentation Improvement Program or CDIP. It’s a very standard process of creating as well as maintaining data that are connected with the patient’s health and wellbeing along with the medical treatments given. Nearly all medical data necessitates assessment regarding accuracy and precision given that the medical needs at present are becoming advanced. Any kind of error in the critical aspects influencing a medical care program could endanger both the security of the individuals and the balance of the health organization as a whole. Only one problem in the legitimacy and credibility of documents can in fact affect the normal operation of the healthcare facility or a hospital. Trustworthiness can be as significant as simple information associated with the patient’s medical condition.

Medical documents contain very important information regarding the patient’s general condition and disease from admittance to release. Health reports work as illustration of the actual affected patient that can be utilized by medical experts when creating the most effective health choices. Making use of the technology advances and software programs for documentation currently available, physicians can get access to personal data and give health cures at any time. Because of the ability of technological advancements and computer software, the documentation system of health centers improved and also the relationship and rapport between health care staff and the patients.


One of the main reasons for medical documents is to represent patients clearly in relation to their medical conditions while many of the health treatments which happened are documented in depth. Clinical documentation should be simple but clinically proper. It should be completely comprehended by all medical care staff and also by the non-medical workers. This really is critical non-medical workers to acquire a good understanding concerning the condition of patients. Many personnel inside a health center will in a way take part with patient health care somehow. Documentation improvements are performed to give precision, convenience, and ease of access of health records. They are likewise helpful for investigation, examination, and case studies.

CDIP are essential in the medical industry and they have been affected by the technology of today. The application of present day techniques and operations has overcome the disadvantages of the traditional methods. The whole process of noting and looking after health records are designed much easier and easy to the smallest details. These adjustments show the standards of medical organizations and considerably influence their whole standing. Keeping up with the requirements and providing openness during the process of data gathering while ensuring security, accuracy and precision are the principal function of clinical documentation.

Strategic Process with Clinical Documentation Improvement Program

All medical institutions aim in having the best quality of health service they can provide. They intend to gain internal control of their institution. This is possible by giving enough attention into the quality of clinical documentation. There are many available companies that provide services on clinical documentation improvement. An option is to outsource from them to assist in improving the documentation process.

A medical record audit will also be needed in having a good quality of documentation. This is to see where the problem is in the existing system. This will be the starting point of modifying the existing system. In order to reach development, the negatives and insufficiency of the current system must be the guide. Assessing the existing system should be thoroughly done.

clinical documentation

Choosing the right type of clinical documentation improvement program that will suite the medical institution is important. It will be based on the facilities present in the institution, size of the area covered, location, and the ability of the medical personnel. The institution should be willing to undergo certain changes in the hospital. One example is investing in additional facilities like computers for the betterment of medical data record storage. Another important thing needed is the improvement not only the system but also the personnel involved. They must be willing and diligent enough to acquire additional education pertaining to the new facilities installed. Being able to use the new facility is the goal of attending trainings. The resource will be useless if it is not able to function due to the lack of knowledge of the medical personnel responsible.

With the help of a clinical documentation improvement program high standard of medical health service is attained. Clinical documentation specialists are usually involved in the process. A Health Information Management or HIM officer is also another skilled personnel that can manage the clinical documentation process. They are responsible in interacting with patients to obtain necessary information such as patient history, previous health programs enrolled, treatments given, drugs prescribed, allergies, and so on. The data gathered is then coordinated to the physician to evaluate and formulate strategies for treatment. Also, all laboratory tests, procedures, and drugs prescribed to the patient by the physician must be seen in the medical record.

If the work strategy will be done systematically and as planned, the documentation improvement program will be successful. High quality health service is possible and revenues will increase. It is only a matter of picking the right program and also a reliable service provider in guiding the institution in a better path.

Advancements in Clinical Documentation Improvement Program

A medical record is an essential part of the healthcare industry. Enough attention is required to meet the demands in this field of health service. To constantly improve the service of health records a medical documentation improvement program is used. Accuracy in the data recorded is a must. Clinical documentation is regulated by federal bureau. They check whether the quality of health service provided by hospitals meets their standard. Also, they ensure that the payments given by patients equal the quality of the treatment results.

Information of patients is collected during its whole stay. Data gathering starts from the period of admission of the patient up to its discharge. Included in the documentation are the laboratory procedures conducted, diagnosis of physicians, medicines taken, and the equipments used. Also, the patient’s medical history and any other medical operations undertaken for the past years are recorded. Due to this vast information to take, clinical documentation improvement program CDIP is utilized to provide the best possible way in documenting these kinds of data. Enhancements in the coding system are managed by the program. Devising an easy yet efficient way of coding is one method of clinical documentation improvement.


The use of software in creating medical records and charts is one innovation in technology to raise the standard of documentation. By creating databases for storage of patient profiles, accessibility is improved. Uniformity in the data is very important for the whole medical institution. Every department must ensure that the data they are looking is synchronized with each other. With the help of this database, all medical staff will be looking at the same information which increases accuracy. This also provides a better way of editing and dissemination of data.

Many clinical documentation improvement programs are produced by several service providers. They are very available and it depends on the company which service provider to choose and entrust the documentation system of their institution. It is important to be open in any changes brought about by the program. This involves addition or removing the old and traditional way of documentation. Using advancements in technology is an advantage. Computers are widely used these days and many are removing the traditional way of documentation because of its tedious and long process. The new way compresses the procedure to improve the work speed. This increases the work efficiency in hospitals. As a result, medical providers can focus more on their work for the benefit of the patients.