Why Is Clinical Documentation Important?

Introduction
In various healthcare organizations, accurate and precise clinical documentation is extremely important. Moreover, it is becoming extra imperative as the healthcare landscape is constantly shifting. Clinical documentation is not only vital in authentication of care provided to a patient but similarly for the reason that it shares significant information with successive caregivers and enhances claim processing. Therefore, clinical documentation improvement programs are very significant in any healthcare facility that distinguishes the need of comprehensive and correct patient documentation. In clinical documentation, various codes reflect different elements. For example, there are codes that that reflect the severity of the disease
Over 80% of the acute care hospitals in the United States have established clinical documentation improvement (CDI) programs (Breuer & Arquilla, 2011). Furthermore, there are various key players involved in the CDI team. The players include clinicians, (CDS) clinical documentation specialists, as well as inpatient coders. Other members who may get involved in the process include the nutrition department, care management, and the wound care specialists. Subsequently, clinicians refer to health care specialists who are qualified and certified to treat patients and they include nurses, doctors of medicine, nurse anesthetists and many more within the broad term. What is more, the clinicians play a vital role in the CDI program as they are acquainted to the patient as well as the ailment being treated. Their documentation determines the complete course and controls all that ensues afterwards (Breuer & Arquilla, 2011). Awareness, competence and collaboration are the three major components of clinician participation in the CDI