The last few years have been a period of rapid change in the field of health care and medicine. Traditional practices have been thoroughly assessed and analyzed for possible corrections and improvements. One of the areas that have been given much attention is the field of documentation. The current systems being used for different operations are considered to come up with the most appropriate improvement programs. Same thing goes with clinical documentation where traditional practices of record keeping have been revised and enhanced due to the disadvantages that hinder the chances of achieving goals which include providing high quality medical services. With the introduction of clinical documentation improvement programs, the tasks involved the incorporation of modern technology to traditional practices.
The different aspects of medical institutions were improved by introducing different IT solutions and computer applications. The improvements are focused on record keeping, diagnosis, nursing documentation, operations and surgical data, and administrative aspects. The main goal is to achieve reliable clinical documents by implementing tasks suggested by clinical documentation improvement programs. Clinical records will be made reliable and accurate enough to support faster medical plans and solutions. The current system being used will have to be analyzed and reviewed carefully, thus requiring the need for an external clinical audit which can provide unbiased review and identify possible areas for improvement and corrections. This is one of the requirements that lead to the identification of programs that promote clinical improvement.
Before implementing clinical documentation improvement programs, it is necessary to consider the past and current processes and procedures being used by a certain hospital. This makes it easier to identify the most suitable type of program that will not give a hard time to medical personnel when it comes to adjustments. Also, it is very important to make sure that minimal time and operation procedures will be sacrificed as the whole institution moves towards the goal of documentation improvement. Most of all make sure that patients will not be at risk during the adjustment periods. This can be done by ensuring that medical personnel can easily adjust to the changes brought by clinical documentation improvement programs. For instance, if it involves electronic medical records or EMR, make sure that proper and enough training are provided to physicians who will handle them.