Fixing the broken system: Improving clinical documentation in health care
The degradation of clinical documentation in electronic health records has a direct impact on patient care and quality metrics, and is due to factors such as a lack of respect for documentation as a means of communication, a lack of understanding on the connection between documentation and codes/reimbursement, and a lack of proper training on best documentation practices. To improve documentation, institutions should implement reciprocal auditing and consider a documentation timeout to emphasize the responsibility of documenting for advancing patient care.