In her white paper, Silpa Saladi, Client Operations Director, discusses the importance of effectively closing the clinical care gap within the healthcare industry.
Please click on the video to the right to learn more about Silpa, her paper’s key takeaways, and her motivation for writing on this subject.
To discuss this white paper at length, please contact the author using the information provided at the bottom of the article.
"L'essentiel est invisible pour les yeux." That which is essential is invisible to the eyes. - The Little Prince by Antoine de Saint-Exupery
What are the most crucial aspects of an effective patient-provider encounter? Most can agree the primary goal is to prevent ailments or to cure them. For the patient, proper treatment of any health issue begins with a visit to the doctor and complying with treatment. For the provider, it is ensuring they thoroughly examine the patient and appropriate management options are assessed and prescribed. However, a vital step in accomplishing a successful visit is often missed.
Although it is not inherently evident, incomplete medical record documentation can have detrimental effects. For example, there are instances where a patient with an allergy to eggs receives a flu shot or one with a peanut allergy prescribed Prednisone, both containing their allergens. Missed documentation can result in fatal consequences. These cases generally end in legal proceedings but cannot bring the patient back to life.
The expectations put on physicians are immense; it is no simple feat being an everyday superhero and saving lives. With each encounter, providers are tasked with intricately examining their patients, diagnosing their illnesses, ordering appropriate labs/diagnostic exams, and coordinating care with other providers who may be involved; all while ensuring they stay on schedule and see every patient. In addition, we expect them to document each of those key factors, the entire interaction they had with the patient and ensure they meet the plethora of coding requirements.
Complete and accurate medical records enable physicians to make more informed decisions about managing a condition, ensure proper follow-up care and provide insight into the history and evolution of an individual's illness or injury.
The importance of documentation is not to be underestimated; several risks may result from an incomplete record, such as:
Although documentation serves many purposes, the main goal is to ensure patient safety:
"If you don't keep proper records, it is like driving without a speedometer – any accident that happens would mean negligence on your part." Dr. Sudeep Khanna.
What steps can be taken to ensure proper documentation?
Utilizing the patient to fill in any documentation gaps and sharing appropriate information can encourage patients to be active participants in managing their health. When documentation becomes a two-way street, it is more complete. Regular check-ins with patients with chronic conditions such as diabetes, hypertension, or rheumatoid arthritis is an easy way to engage patients and is also a billable service.
Since doctors are not coders by trade, it is tremendously valuable for them to utilize coders with clinical backgrounds like themselves. By understanding how various signs and symptoms present themselves clinically or a diagnosis is missing from the medical record, they are able to identify documentation deficiencies and provide valuable feedback to physicians easily.
Technology-enabled solutions can prompt providers for additional documentation as they are typing their notes. When a provider documents a diagnosis, integrated Ai solutions can prompt clarifications on specificity/severity, required diagnostics labs, or other guideline requirements.
For example, if a provider confirms heart failure, it is necessary to document evidence and assessment and plan; chemotherapy infusions must have a documented start and stop time.
By teaming up with Vee Healthtek, you gain access to the top talent in the industry. Our clinically-trained coders, expert IT consultants, and physicians on staff understand exactly what your practice will benefit from by being equipped with the information it needs. Closing clinical care gaps begins with prevention and ends when you choose the right team.
