Clinical Documentation in Patient Care

Top 3 Benefits of Clinical Documentation In Patient Care

December 09, 2019 | 12.30 PM EDT

Patient care is one of the primary goals of the healthcare industry. The patients are the end-users of healthcare services. The goal of providers and healthcare institutions globally is to provide better patient care with existing and advanced resources. Clinical documentation has been a diligent practice among the medical fraternity for several centuries. However, it has surpassed traditional methods like medical transcription and evolved into a more inclusive practice influencing the patient experience.

Mapping Patient Journey

Clinical documentation is at the heart of the patient’s medical journey. An integrated clinical documentation application powered by Artificial Intelligence such as CascadeMD benefits both independent providers and healthcare institutions. It helps capture and convert unstructured health information into structured patient data. The health information includes patient history, provider’s notes, lab results, and x-rays e. apart from other clinical data.

Mapping Patient Journey

The infographic highlights the patient journey for cancer (oncology) patients. Initially, they visit a general physician (GP) owing to their deteriorating health condition. The GP will then refer them to an oncologist for cancer treatment. The oncologist will direct the patient to the pathologist for further testing and diagnosis. The oncologist decides on the patient’s treatment choices depending on the test results of their pathology report. Finally, the patient will seek the support of a radiologist for chemotherapy or a surgical oncologist for surgical intervention as advised by the oncologist. The nurses experienced in cancer treatment will guide the patient through different therapy cycles and regimen changes during the course of the treatment. The healthcare outcome of cancer treatment could be either survivorship or disease progression which differs from every patient.

Clinical documentation facilitates exchange of patient information and clinical data between providers from different fields of specialization for better treatment recommendations. It promotes the ease of access to patient data at the right time to make the right decisions. AI-driven applications such as CascadeMD apply ultra-quick documentation technology using speech recognition engine and inference engine to support clinical decisions among providers and healthcare institutions.

Translating Health Information

The health records management department adopts the Clinical Documentation Improvement (CDI) program to manage and optimize medical records including patient encounters and clinical data. A well-documented medical record is processed and coded to provide a detailed account of the patient’s diagnosis, procedures, and treatment according to the International Classification of Diseases (ICD) codes. It supports current and continuing patient care in compliance with federal regulations. However, translating medical documentation into clinical terminology requires clarity, accuracy, and specificity.

Translating Health Information

According to the World Health Organization, a health record generally refers to a broader view of healthcare in many countries. It is a single record of all data on an individual's health status including birth records, immunization records, and records of all illnesses and treatments given in any hospital across the country. Currently, very few hospitals maintain a comprehensive health record. The medical record is, therefore, the most accurate term used to refer records on a patient’s clinical data in the healthcare industry. Clinical Documentation helps providers and healthcare institutions to make better clinical decisions based on the medical records that are evaluated and monitored over the long term. CascadeMD is an AI-driven clinical documentation app that can review and extract meaningful information from archived paper records. It supports mining a lot of valuable data and trends from unstructured records both in print and digital.

Streamlining Healthcare Workflow

Streamlining Healthcare Workflow

Clinical documentation proves equally critical to strategic planning, clinical research, medical education, and healthcare policy development at both regional and national levels. It has evolved past traditional methods like medical transcription into a more inclusive practice influencing the patient experience. The providers leverage the patient data captured through clinical documentation to augment patient evaluation and treatment including the patient history. For example, an independent provider or healthcare institution will need to maintain a comprehensive health record to track and monitor the progress of a patient who is treated by providers with different specializations over a period. It demands a comprehensive process and streamlined workflow to ensure the quality of patient care. The entire healthcare ecosystem adheres to a set of goals and guidelines related to clinical documentation. They can effortlessly manage and deliver healthcare services worldwide, 24x7 with the support of AI-driven clinical documentation such as CascadeMD.

Technology in healthcare, especially Artificial Intelligence in healthcare promotes advanced clinical documentation and better patient care. The role of clinical documentation is to deliver better patient care while simultaneously improving the productivity and efficiency of providers and healthcare professionals. Eventually, it results in increasing Return on Investment (ROI) for providers and healthcare institutions over the long term.