4 ways clinical documentation can improve quality of work and life for clinicians

May 20, 2021
Categories: Home health, Hospice, Palliative care
Reading Time: 4 minutes

Today, more patients seek the comfortable, familiar environment of home, and they expect their home health or hospice care provider to match—if not exceed—the level of care provided in a skilled nursing facility or another post-acute care setting. That means more services must be performed at the bedside to ensure quality and continuity of care. And home healthcare clinicians are charged with meeting these expectations while maintaining compliance with all healthcare regulations. But delivering the highest quality of care to patients along their health journey in this care setting can be a daunting task if clinicians do not have the right healthcare tools and solutions for accurate clinical documentation.

One of the most time-consuming tasks for clinicians involves clinical documentation. From completing assessments and documenting details of an evaluation to charting, a clinician’s documentation is key to a home health or hospice agency getting reimbursed for services. But many home healthcare organizations are slow to adopt a platform designed to help clinicians focus more on direct patient care and less on the laborious—but necessary—administrative work, including clinical documentation.

There are fiscal advantages organizations can gain by using EHR software that includes a clinical documentation improvement (CDI) application, but what agencies may overlook is the advantage clinicians also gain. Clinician burnout is a real problem. Routine stressors like administrative work can be alleviated when clinicians have access to tools crafted to lighten their daily workload (i.e., those daily tasks not involving direct patient care). Let’s look at four ways leveraging CDI software can improve the quality of work and life for clinicians.

1. Fewer documentation errors

Clinicians understand the need to document in a timely, precise, and legible fashion. And they realize if the information is not clearly documented, there is no proof that it happened, which can impact billing and payment. Streamlining the documentation process means clinicians can complete a critical part of the patient encounter to satisfaction with an accurate account of the patient’s current health status. With the right technology platform, clinicians can submit electronic signatures on all patient-related documents, and the documentation is accessible promptly—often in real-time—to the appropriate parties. Not only does clinical documentation help to accurately capture patient encounters; it also allows clinicians to complete documentation in a timely fashion.

2. Accurate prescription orders

Incomplete or inaccurate medication documentation can contribute to inappropriate medication administration that can lead to adverse drug events. The medication process can include several steps and exchanges of medication-related information that are critical to the patient’s treatment and recovery—information that is prone to human error. Clinicians rely on accurate and prompt medication administration to ensure all care providers are fully aware of any new prescriptions, medications that a patient should no longer take, or other related updates or instructions. CDI software that supports an ePrescribe integration makes it possible for medications to be added and updated in a patient’s medication profile. This option facilitates the efficient transfer of medication data and helps to eliminate transcription errors that can occur if a clinician manually enters prescription information.

3. Enhanced quality of patient assessment documentation and care

Communication gaps can result in serious consequences for both patients and care providers. Whether it’s misplaced referrals or outdated medical records, the more care providers interact across the care continuum, the greater the risk of patient information losses or care overlaps. Such breakdowns in care continuity can lead to lost patient encounters for the care providers, misinformed decision-making by clinicians, and poor patient experiences.

Interoperability is a big word in the healthcare industry, but not all EHR platforms fully embrace its meaning based on their software capabilities—or lack thereof. Integrated CDI functionality helps to facilitate interoperability through a patient-centric information flow. Systems are in place to monitor patients; documentation is transferred, and communication tools link patients and their families to caregivers. Patient encounters can be properly documented and shared without delay with other care providers. Not having full access to patient data in real-time means clinicians don’t have a full picture of a patient’s health status, making it a greater challenge to treat appropriately. Clinical documentation improvement can open the door to better care continuity and improved quality outcomes.

4. Greater compliance

The ability to better manage workflows and develop consistency in documentation throughout the care continuum is key to creating the work-life balance clinicians seek. But with ongoing changes in healthcare regulations that impact clinical documentation, maintaining compliance is also foremost in their minds. And getting clinical documentation up to speed with regulatory requirements can be simplified using a CDI platform that offers built-in compliance checks and balances capabilities, which help caregivers achieve full compliance with all required clinical documentation. Other capabilities can include:

  • Configurable reporting that helps identify and address documentation compliance issues
  • Speech-to-text technology for faster charting and more accurate patient data entry
  • Accountability tools designed to help measure patient outcomes and optimize clinical performance

Integrating CDI software with your EHR can yield higher clinician satisfaction

Convoluted processes and repetitive tasks often stand in the way of clinicians as they strive to treat patients to the best of their ability. A CDI platform can be a powerful tool that enables clinicians to increase the speed at which they complete documentation, allowing more actual patient engagement. CDI software also has the potential to facilitate more seamless clinician workflows, so the stress of having a demanding patient workload is less.

MatrixCare software helps to improve the quality of clinical documentation and increase an organization’s revenue stream

Thriving in today’s home health and hospice industry requires gaining a competitive advantage. Working with an inept clinical documentation platform can weaken your competitive standing, and ultimately, your bottom line. By adopting or upgrading clinical documentation automation, clinicians can spend more time treating patients, leading to a higher-quality rating and consequently more referrals. Ultimately, by allowing clinicians to spend more time at bedsides, an organization’s revenue stands to increase.

MatrixCare has a robust EHR solution that includes clinical documentation software that is uniquely designed by clinicians for clinicians. Our CDI solution can ease the administrative burden that contributes to clinician burnout and job dissatisfaction.

Want to learn more? Let’s connect!

Chris Pugliese
Chris Pugliese

Chris Pugliese is a Senior Product Manager of Integration and Interoperability for MatrixCare. Chris has spent the last decade working with post-acute technology and EMRs, and the last 5 years focused on interoperability. His strength is enabling technology, as well as educating on the growing importance of interoperability and its benefits to the post-acute care settings. In a short time, Chris has become a leader, spearheading integration and interoperability initiatives within and outside of MatrixCare. Recent industry committee roles and responsibilities include: Leadership Team Member for the Post Acute Interoperability Work Group (PACIO), Technical Lead for the Functional Status Subgroup for the PACIO initiative – developing FHIR Profiles for Functional Status, CommonWell Health Alliance Use Case Committee member, CommonWell Health Alliance Specification Workgroup member

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