Digital clinical documentation is a modern way to document patient health. It can improve the quality of care for patients and make it easier for doctors and nurses to communicate with each other about what’s happening with their patients.
What Is Digital Clinical Documentation?
Digital clinical documentation is creating, managing, and digitally storing clinical documentation. Healthcare providers are often encouraged to get the CDI pocket guide as it helps them stay on track with the latest updates within the healthcare industry and maintain secure details of the patients.
Importance of Digital Clinical Documentation
Digital clinical documentation is a system that enhances the workflow of medical professionals and makes it easier to access patient information. The use of digital documentation can reduce errors, improve patient experience, support the business goals of your practice, and help make it more efficient.
This is because:
- Digital records are always up-to-date (no need for manual entry).
- It’s easy to share information with other healthcare professionals.
- There are fewer mistakes because you don’t have to transcribe from paper notes.
Many healthcare providers have already opted for digital clinical documentation for the reasons mentioned below:
Consistency of Clinical Documentation
- Clinical documentation is a critical component of the electronic health reporting system.
- Clinical documentation is an essential part of the patient’s medical record.
- The advent of digital clinical documentation has improved consistency in clinical communication and promoted more accurate reporting by healthcare providers.
Better Access to Patient Information
Digital clinical documentation has many benefits, including:
- Improved access to patient information. Since all care team members can see a single, complete record of a patient’s health and history, communication is smoother—no more lost charts or miscommunications between doctors, nurses, and other care team members.
- Interoperability allows information to be shared between systems and organizations. This means that patients are no longer limited by their doctor’s practice or hospital system; their medical data can follow them wherever they go for treatment (and if it doesn’t yet exist in one place, it can be created).
No More Lost Charts
You’re not going to have to worry about lost charts anymore. With digital documentation, your paper records are converted into electronic documents and stored safely in one place. This is also beneficial for patient privacy.
In the past, your patient information could have been easily accessed by anyone who had access to the chat room or file cabinet—and that includes patients themselves if they wanted to read over their old charts! There is no more misfiling charts or losing them in piles of papers on someone’s desk with digital documentation.
Improved Communication Between Healthcare Providers
One of the most significant benefits of digital clinical documentation is improved communication between healthcare providers. Digital clinical documentation offers many potential enhancements: real-time communication, efficient handoffs, and improved spousal/family caregiver involvement.
For example, when forms are completed and transmitted electronically to the receiving provider, there’s no waiting for faxes or paper copies before another provider can see your patient.
This saves time—a precious commodity in busy hospital settings—and also promotes better care coordination across different departments and specialties because the information is readily accessible at any given moment via mobile devices.
Improved Safety for Patients
Clinical documentation is a significant part of the healthcare industry. The importance of clinical documentation cannot be overstated; it’s essential for patient safety, reimbursement, and other aspects of care.
However, traditional systems used for clinical documentation are inefficient and outdated. Physicians spend an average of five hours per week completing paper-based forms—and that’s not even counting the time spent waiting for forms to be filled out!
In addition to being slow and cumbersome (not to mention environmentally unfriendly), these outdated methods are also prone to errors: Studies have shown that up to 50 percent of medication orders can contain errors in their dosage or route of administration alone!
With digital clinical documentation tools, this problem is solved. With its intuitive interface and advanced analytics capabilities—plus features like electronic medical record connectivity—you’ll see improvements across your organization in terms of safety (reduced medication errors), infection rates (better hygiene practices), outcomes (improved patient care), length-of-stay reductions and more!
Improvement in Productivity for Physicians and Nurses
- The quality of clinical documentation is improved.
- Patient outcomes are improved.
- The cost of care is reduced, and revenue increases.
- Regulatory compliance is enhanced.
- Physician satisfaction is improved, which leads to better patient care and retention of physicians in a practice or hospital setting.
Real-Time Data Capture, Analysis, and Reporting
In addition to improving the quality of care, real-time data capture and analysis can help you quickly identify and address problems in care.
- Lack of patient adherence to treatment recommendations, including non-compliance with drug regimens or medical devices.
- Difficulties with communication between patients and providers (for example, patients who do not understand their condition).
- Medication errors during administration by providers or pharmacy staff.
Real-time data also allows for real-time feedback that can be used for continuous improvement efforts across the health care enterprise.
Digital Documentation Is Good for Your Business
In addition to the many other benefits, digital documentation can improve the patient experience and be good for your business.
- Greater Efficiency: With digital documentation, you can share information about patients with different providers at different offices in real-time without manually entering data into multiple systems or spending valuable time searching for it. This enhances efficiency throughout your practice and improves revenue cycle management by reducing billing errors and delays.
- Improved Revenue Cycle Management: The ability of physicians and other healthcare professionals to see their patients’ entire medical histories in one place allows them to provide better quality care while focusing on what’s most important – treating their patients’ needs rather than spending time chasing down historical records (which could be anywhere). It also reduces the risk of incomplete records and compliance issues related to duplicate billing or lack thereof when there are incompatible versions of vital signs between doctors using different electronic health record systems.
Conclusion
Digital clinical documentation is the future of healthcare. It will continue to evolve and grow, but its benefits are undeniable. Improving efficiency, safety, collaboration, and quality of care are just some of the positive outcomes digital clinical documentation can bring to the health care sector. Healthcare professionals can increase revenue by implementing this technology while simultaneously improving their patients’ lives.
