Managing the work required for your role can be a daunting task. You must observe all of the rules and regulations for work performed and maintain an accurate picture of your clinical documentation to meet the proper reimbursement requirements within your place of service. The key to accurate clinical documentation is smart workflow design. Although many of my columns center around workflow, understanding why particular documentation elements are of critical importance remains paramount. In this column, we will discuss how your documentation creates workflow dependencies, which are vital for your business to be successful within your department. Getting to the details within each dependency is step 1. Understanding why these steps are important is step 2. Applying these steps to your area of business is step 3.
According to the American Health Information Management Association, clinical documentation is at the core of every patient encounter. In order to be meaningful, it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more importantly, to a healthy patient. To that end, CDI has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date.
In order to capture proper clinical documentation, it is important to configure your workflows with the appropriate elements to meet the rules and regulations of your workplace. One of the first steps is to define your day-to-day structured activities. Understanding each part of your process, no matter how small, is critical. Each action has dependencies within a workflow including the responsibilities of your staff or resources used, rules of governing bodies, and requirements for clinical documentation. The details of each documentation dependency in a workflow are defined by the responsibilities performed by the resources within your place of service. The responsibilities are translated as physical actions or tasks. The actions or tasks form the proper steps for documentation and payment rendered.
In order to define the dependencies within a certain workflow, you need to sit down with your team and discuss the work performed within each discipline. Once the conversation starts, it is imperative to deconstruct the actions taken to complete each task. Each individual task becomes the basis for the actions taken by your team and translated into the clinical documentation for the work you perform.