The aim of this review is to describe the interaction of clinical documentation
with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists.
An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation
Selected publications included those that described coding, medical record documentation
, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation
Improvement programs, medical scribe programs, and various payment models.
Relevant information was extracted to highlight the impact of diagnosis documentation
on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital’s Clinical Documentation
Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation
were incorporated into this review.
Available data in the literature indicate that documentation
of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation
of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation
have been increasing, especially with the introduction of electronic medical records.
of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation
on patient care as well as steps to decrease the associated burden.