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Clinical Documentation Improvement Program – Industry Trends

clinical documentation improvement program is definitely one of the important segments of the medical industry and has made much progress in the recent years with the advent of technology. However, the process of documentation has always held in important place though in the early days it was a long and laborious process involving hand written documents that were often not legible!

Clinical Documentation Improvement Program for the Patients

Clinical Documentation strongly believes that innovative use of technology can improve the experience of healthcare for both healthcare professionals and patients. Technology has a role to play in helping to reduce costs, control the prevalence of chronic diseases and to enable consumers to play a greater role in managing their health.

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Clinical Documentation Improvement Program and Its Functions

The Emergency Department Tracking module is another aspect of clinical documentation improvement program for a robust patient monitoring with multiple functions designed exclusively to meet the needs of the emergency department’s busiest hospitals. This system, developed according to high standards of emergency workers, including nurses, doctors and administrative assistants, provides the clinical team with the tools it needs to manage and track patient treatments, triage and admission to discharge, while increasing productivity and improving the allocation of resources.

Clinical Documentation Improvement Procedures

The clinical documentation improvement module is part of the solution Oacis EMR, an electronic medical records system company fully interoperable. Clinicians use the navigation features of the system to quickly enter and view clinical data seamlessly longitudinal information on their patients. This module facilitates the sharing of patient information between clinicians and disparate systems. Streamline clinical documentation eliminates redundancy in data entry. Security permissions allow clinicians to access only the appropriate sections of electronic medical records. The solution construct enables the supervision of professionals trained using a feature-cons signature, which can be used in all clinical documentation improvement module.

Functions of Clinical Documentation Improvement

The clinical documentation improvement is an important tool for improving patient safety because it sends alerts to clinicians before the execution of a service request or order. These alerts, based on our system to support decision-making, inform clinicians of the potential repetition of orders or requests for services, and risk of adverse interactions between certain drugs or treatments.

Clinical Documentation Check List

Clinical Documentation has become integral part of the health care services, as it is excellent only for record keeping, but setting the highest possible standard for medical record keeping which are often fallen back up on for research purposes. However, there are certain governing bodies that regulate the standards and the norms to be followed in keeping these documentations.

Clinical Documentation and Clinical Governance

The term Clinical Governance is used for describing a systematic approach in maintaining and improving the health care system and provide unique care to the patient concerned. The term gained popularity after the Bristol Babies Scandal in 1995 and strict standards of health care are set by the clinical governance which includes but are not limited to high standards of care, accountability for the standards set, transparency in the responsibilities allotted accompanied by constant improvement. Clinical Documentation too has become a part of the Clinical Governance as strict standards are to be maintained while documenting anything related to the patient or the medical treatments he is undergoing.

Clinical Documentation in Clinical Trial

A clinical trial is a clinical research which involves controlled test of the new drugs or ‘new invasive medical device’ on human beings and is conducted under the regulatory acts of the FDA before it is made available for general public use or general clinical use. These clinical trials are mainly conducted to allow safety of the data to be collected for health related studies involving therapy protocols or related to the introduction of new drugs in the medical market of a particular country only after a certain regulatory body has approved of it.

General Rules in Clinical Documentation

Clinical documentation has always been an integral part of the medical treatment of the individual as it relates to the patient and is a detailed record of each problem and the care given in that respect. So these documentations are medical data involving every details like the assessment of the health condition of the patient, the plan and procedure of the treatment, problems if any and of course, most importantly, the patient’s response to the treatments that he is receiving. In short, the Clinical documentation has all the details of the patient from the time of admission to the time of discharge. These data collected and processed needs to be accurate, as they are often needed for research purposes.

Clinical Documentation With Ready Templates

The introduction of the ready templates in Clinical Documentation has proved to be a boon in the medical record keeping field. There are ready templates available from the Microsoft Office System that helps to create the clinical documents on ready-made templates that are clinically encoded and can be retrieved back using the Microsoft Office.

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