Accurate clinical documentation of records directly impacts patient safety

Properly done clinical documentation shows a true picture of a patient’s condition, and therefore increases safety.

Talking at the session on “Supporting patient safety through high quality clinical documentation” on November 6, Tammy Combs, Trainer and Director at AHIMA CDI and Clinical Foundations said: “We often think about the direct impact clinical documentation has on patient safety but it is important to understand how it works. Clinical Documentation Integrity (CDI) teams document in real case scenarios and we have several examples of the impact that documentation integrity has on patient safety itself.” Combs also said: “It is important to think of CDI being at the core of the patient record because it is telling the patient’s story and we want to make sure that we are telling an accurate story; for that we have to make sure that the documentation is meaningful, timely, accurate and also reflects the scope of services that were provided.” CDI impacts patient safety as it supports medical decision making, helps identify missing or incomplete information, recognises potential safety concerns in patient care, and also validates that documentation has been added to patient care.