Clinical Documentation Insight

Working in Silos is Never a Good Idea

The hospital has an electronic medical record system.  Management of the clinical documentation team originally decided to send physician clarifications via email.  The response rate from the physicians was poor.  CDS management decided to meet with the physicians and get their opinions as to how to send clarifications.  The physicians suggested using the message center in the EMR.   This allows the physician to see the clarification in the patients medical record thus making it much more convenient to answer.

So, working with the physicians to determine the best process for clarifications will result in an improved response rate.
-Randy Wagner, BSN,RN,CCS
 http://www.dcbainc.com/clinical-documentation-improvement-program/