Improving Your Clinical Documentation

NursingApril 13, 2017

Whether you are enrolled in an online nursing program, or you are pursuing your RN to BSN degree at a bricks-and-mortar institution, an extremely important skill to master is proper, efficient clinical documentation. Most RN to BSN programs will spend at least some time emphasizing the importance of this task. To be frank, it may be viewed as drudgery by some nurses, but excellent clinical documentation is utterly indispensable to good nursing and a properly functioning facility.

Clinical Documentation Improvement Specialist

The business of proper clinical documentation is so important, in fact, that many scholarly articles have been published addressing the issue. There’s even a specialty in nursing called a Clinical Documentation Improvement Specialist (CDIS), and there are programs within many institutions dedicated to the improvement of clinical documentation. Clearly, this is a key area of nursing that we must always strive to perfect.

Of course, clinical documentation is central to every encounter you have with a patient as an RN. Whatever you do, whatever vitals you record, whatever medications you administer, whatever actions or procedures you perform, it is essential that you document what you did. In as much detail as possible. You documentation must be accurate, precise, and timely. Your notes should be clear and objective. The longer you wait to document something, the more likely you are to forget an important detail or to make an error. And remember that omissions to the record can be just as bad as incorrect entries.

Keep in mind that the documentation you provide, whether it is entered into a digital documentation system or entered on paper, will be used by coding specialists to generate standardized data that will inform the care and treatment of your patient going forward. Since about 2007, medical providers have increasingly focused on the clinical documentation aspect of healthcare, noting that mistakes and omissions may have an impact on everything from patient outcomes, to reimbursement, to research efforts.

Why Accuracy Matters

Coders do not have the clinical knowledge that you have worked so hard to obtain, so they can only “translate” what they see before them. They have no way of evaluating a note that might seem inaccurate or otherwise questionable to you. It is up to you, then, to provide proper clinical documentation in the first place, so errors do not creep into the system. Documentation affects everything from patient care and treatment decisions, to how your institution will be reimbursed for the services it provides. Mistakes can and will be penalized, and could affect your entire institution, so accuracy and comprehensiveness are crucial.

If you are considering becoming a CDIS, you will need certain skills, such as ample clinical experience, the ability to analyze—and prioritize—data rapidly, and critical thinking skills that will allow you to identify sources of potential inaccuracies and seek ways to improve the recording/documentation process for everyone involved. You should probably enjoy teaching, as well, because a big part of the job for an effective CDIS involves training and coaching other healthcare professionals regarding current documentation standards and practices. Occasionally, the stakes will be high, and the pace rapid, so it’s also important that you be able to work quickly and think on your feet.

Your Role

As a nursing student working to obtain your BSN, you should focus on making accurate, timely documentation a top priority.

These days, most nursing students will work with Electronic Medical Records (sometimes called Electronic Patient Records (EPRs), or Electronic Health Records (EHRs)). These systems enable hospitals and other medical facilities to store and share medical records and other information digitally, across multiple platforms. These systems are becoming increasingly common and they are viewed as helping to prevent errors and improving the speed of obtaining important patient records in order to improve healthcare delivery.