Clinical Document Integrity (CDI) is a profession that has previously been viewed as simply a revenue-seeking program. But that couldn’t be farther from the truth. CDI programs that promote high-quality documentation not only support the capture of correct reimbursement but allow the care provided to the patient by ensuring all the information within the health record is of accurate quality and supports informed medical decision-making. 

For proper revenue cycle management Credence Global Solutions offers an extremely wide breadth of tools and expertise for our clients. For our clients interested in outsourcing laboratory billing, there are many solutions that Credence can provide in addition to maintaining the accuracy and integrity of important clinical documents. 

Four Reasons to Document Medical Records Properly

1. Communication with Other Healthcare Personnel

Documentation addresses the what, why, and how clinical care is ultimately delivered to your patients. The records used allow other clinicians to understand the patient’s history so they can continue to provide the best possible standard of care for each individual. Proper documentation also serves as a means to facilitate the appropriate patient navigation and coordination along the entirety of a patient’s care, from EM to HM and transitioning into the post-acute care setting.

2. Reducing Risk Management Exposure

Thorough and accurate documentation mitigates risks and reduces the chance of a successful malpractice claim. A well-documented record serves as evidence of treatment and care, helping to alleviate liability concerns in the event of a claim.  It is unlikely you will remember details of a particular case several years later when you are in the middle of a professional liability claim.  Your documentation will be the tool you rely on in this situation.

3. Records CMS Hospital Quality Indicators and PQRS Measures

Documentation captures value-based care metrics that the government is increasingly asking hospitals to provide. These include Hospital Quality Indicators and MIPS measures.

4. Ensuring Appropriate Reimbursement 

A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any “hassles” associated with claims processing, and ensure appropriate reimbursement.

Other reasons why proper medical record documentation is important to include:

  1. Tells the patient’s “story,” the presenting problem and the treatment received
  2. Helps to plan and evaluate a patient’s treatment
  3. Creates a permanent record for the patient’s future care

Ultimately, the solution is quite simple. By entrusting your needs for accurate clinical documentation for claims reimbursement to Credence Global Solutions, you can ensure the highest level of quality care, and in turn, that same level of care can be provided to your patients at your healthcare system. For revenue cycle management, billing automation, or if you’re curious about what it takes to outsource your laboratory medical billing, contact Credence Global Solutions today!