Clinical documentation is the foundation of every patient medical record. People who document in records should meet clinical documentation standards. The record supports the severity of the patient's condition, assessments and evaluations leading to diagnoses and treatment management. Without strong documentation, it becomes difficult to support the medical necessity of services provided, opening the door for additional information requests, down coding, or denial of services. Additionally, in situations where legal action has been initiated, the record will provide the support needed by the provider to justify management and billing. If the record contains vague and ambiguous language, or is missing key information, this advantage is significantly compromised, and may lead to a costly negative outcome. Coders need high quality documentation to determine coding quality and accuracy, and cannot assume a diagnosis unless documented by the provider. Every regulatory agency is placing heavier emphasis on clinical documentation. As the industry moves toward value based medicine and blended payments, rather than fee-for-service, providers must become more focused on the documentation. The advantage really is in the details.

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Clinical Documentation

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