Preventable medical errors occur with alarming frequency in U.S. hospitals. Unavailable patient information and illegible handwriting lead to diagnosing and ordering errors, which compromise patient safety and quality of care. Regulatory agencies and healthcare providers have recognized that by focusing on quality clinical documentation integrity, a traditional hospital can improve patient care, improve reimbursement, and report accurate data which reflects the highest standards of patient care. The implementation of a Clinical Documentation Improvement Program plays an important role in achieving this goal.
In order to improve clinical documentation, the hospital must identify current deficiencies, inconsistencies, and discrepancies in current clinical documentation. A clinical documentation improvement program is a dedicated team of healthcare professionals that will assure that the medical record documentation reflects an accurate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care.
Without adequate tools and procedures for accurate and complete documentation at the point of care, patients can be exposed to errors in patient care. A single mistake can threaten the stability of a medical institution and in worst cases, may destroy the lives of the patients. But liabilities, failures, and risks can be prevented by implementing improvement programs which promote modern tools, programs and applications for clinical documentation.
FHAMC has worked hard to develop a comprehensive and successful Clinical Documentation Improvement Program and Physician to Physician Education Program to offer our member and non-member hospitals.
For more information on these programs, please contact Jennifer Greenhalgh.