7 Key Strategies to Improve Clinical Documentation

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Key Strategies to ImproveClinical Documentation

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Clinical documentation refers to all the information relating to each patient’s encounters with a healthcare facility. Many practitioners consider medical transcription outsourcing as a reliable strategy to create proper medical records.

Strategies to Improve Clinical Documentation

Develop clear documentation guidelines

Plan ahead and hire efficient CDI specialists

Assess existing policies and procedures

Train staff on proper documentation techniques

Review the medical record before the encounter

Have the CDI specialist review claims before submission

Consider the changing health care operational environment

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