Clinical documentation is essential for accurate and effective patient care, as well as for reimbursement and legal purposes. Here are some key strategies.

1. 7

2. 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.

3. Strategies to Improve Clinical
Documentation
Develop clear documentation guidelines
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
Plan ahead and hire efficient CDI specialists

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