Clinical documentation support refers to the assistance provided to healthcare professionals to help them create accurate and complete clinical documentation. Clinical documentation includes the records and reports that healthcare providers create to document patient care, diagnoses, treatments, and other aspects of healthcare. Accurate and complete clinical documentation is important for a number of reasons, including:
- Ensuring that the patient’s medical history is accurately recorded and can be accessed by other healthcare providers as needed
- Providing evidence of the care provided to the patient and the decisions made by the provider
- Facilitating communication and coordination of care among healthcare providers
- Ensuring that the provider is properly reimbursed for the care they provide
- Providing information for quality improvement and research purposes.
Clinical documentation support can be provided by a variety of professionals, including clinical documentation specialists, medical transcriptionists, and medical scribes. They may work with healthcare providers to review and improve documentation, assist with documentation tasks, or provide training and education on documentation best practices. Clinical documentation support can help improve the accuracy and completeness of clinical documentation, which can ultimately improve the quality and efficiency of patient care.