Top Three Clinical Documentation Challenges: Learn the top three clinical documentation challenges and how to address them
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30 August 2017 - 18:27, by , in Blog, Compliance, Comments off

Learn the top three clinical documentation challenges and how to address them

Executing flawless clinical documentation challenges many providers and is top of mind for every health care organization—it prevents compliance issues, financial burdens, and of course most importantly, errors in patient status or care. Achieving even close to flawless documentation is difficult—in part due to all the variables involved with each case. However, there is a way for organizations to significantly improve and therefore gain control of their clinical documentation accuracy—through acuity.

“It is important to talk through documentation errors by question because there is not a single patient that is the same as another on that you’ve taken care of. You can’t carry your documentation over from one visit to the next, it has to be individual.” says Jeri Ann Kelly, Chief Nursing Officer, McBee.

Jeri Ann identifies the top three clinical documentation challenges as follows:

  1. Lack of Documentation
  2. Electronic Medical Records without Narratives
  3. Not Interpreting OASIS Correctly

Watch the video to learn more.

 

About The Contributor

Jeri Ann Kelly, BSN, RN, MBA, Chief Nursing Officer, Principal–McBee

Jeri Ann has more than 28 years of experience in health care. With her background in case management, hospital revenue cycle, and home care and hospice administration, she is able to see patient care through the eyes of a clinician while monitoring financial strength in health care organizations.

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