Clinical documentation is at the center of every patient encounter. In efforts to ensure that clinical documentation is meaningful, there is need to make it timely and accurate while reflecting the scope of services that have been provided to patients. Clinical documentation improvement defines the best practices as well as processes, people, technology, and joint effort that is between the billers and providers advocating for validity, precision, and completeness of provider documentation ( Dehghan, Sheikhrabori, Sadeghi, Jalalian, & Dehghan, 2013) .
While clinical documentation is integral for care provision, it is often misunderstood with some providers feeling that their expertise is being questioned. In overcoming such misunderstanding and making clinical documentation improvement effective, there is need to define professional standards regarding note taking and clinical documentation and ensuring that such standards are congruent to the industry standards. Additionally, the standards should have priorities geared towards brevity, clarity, and the needs of the readers when coming up with guidelines on practice and documentation ( Priyadarsini, 2016) . Defining professional standards that are consistent with industrial standards help in quickly getting the point across regarding the slippery slope on inaccurate coding and faulty documentation.
Delegate your assignment to our experts and they will do the rest.
Additionally, providing training to physicians would prove an integral approach towards overcoming misunderstandings which may prevent clinical documentation process. Through provision of training, it will be possible to get the buy-in of resistant physicians. It should be noted that upon successful training on the importance of clinical documentation improvement process resistant physicians and other providers will assist in spearheading the improvement process ( Dehghan et al., 2013) . Using peers to offer support for the process makes providers to accord priority to clinical documentation improvement process thus making it effective.
Making an effective clinical documentation improvement calls for team effort. As noted earlier, providers feel as though their expertise is being challenged. Thus, it is worth incorporating the ideas of the providers as well as my team members to reach at an agreement on what is best for the facility and its management ( Priyadarsini, 2016) . Agreements that should be made include the quality metrics for the organization and targets that range from financial as well as length-of-stay.
References
Dehghan, M., Sheikhrabori, A., Sadeghi, M., Jalalian, M., & Dehghan, D. (2013). Quality improvement in clinical documentation: does clinical governance work? Journal of Multidisciplinary Healthcare , 441. doi:10.2147/jmdh.s53252
Priyadarsini, P. (2016). A primer on Clinical Documentation Improvement Program. Health Care Academician Journal , 3 (2), 74. doi:10.5455/sad.13-1467646960
