The Importance of Clinical Documentation Tools in Healthcare

Clinical documentation tools provide assistance to healthcare organizations in representing accurately clinical information regarding patients. This information may include health status, health related events, medical visits and different records, and everything is being represented as coded data. Such data translates into top quality reporting, health status tracking, managing reimbursements, and taking care of plenty administrative tasks. With the implementation of CDI, healthcare facilities will increase the accuracy of transforming both administrative and patient information into data.

Thus, healthcare organizations will see a rapid boost in overall clinical efficiency, they will be able to increase revenue and also drastically reduce the data entry tasks done by system workers. The implementation of Clinical documentation tools in hospitals can increase revenue and reimbursement of claims that can exceed 1.5M. Moreover, the implementation of such tools will improve communication between healthcare providers which is important for smooth running of tasks in a medical setting.

Clinical documentation is the pillar of the medical record of a patient. It includes information pertaining to patient care from admission and up to discharge. With complete and detailed documentation, providers can prevent treatment ambiguity. When clinical documentation is not recorded properly, this translates into a higher number of readmissions, sometimes treatment or medication errors and increased costs for the healthcare facility.

Several studies in the field prove that half of the medical records in most hospitals can actually be improved with more detailed and more accurate documentation. With accurate patient documentation overall patient care quality will also improve. Top medical software providers offer complete solutions and assistance for their clinical documentation tools. CDI tools are generally used across hospital settings, but they can be successfully implemented in almost any healthcare sector. These programs are used worldwide for more than 20 years, and CDI tools are becoming more and more common across healthcare settings both public and private.