What's On News June 2017 Clinical Documentation and Coding Improvements Update

News

Clinical Documentation and Coding Improvements Update

Tuesday 27 June 2017

Since late 2016, there has been an increased focus on improving clinical documentation across Mater. This focus has been driven by benchmarking and ongoing audits that have identified gaps in Mater’s clinical documentation which can have significant impacts on the efficiency and quality of our patient care.   

Where clinical documentation is not specific or diagnostic terms are not used to describe treatment decisions and findings, doctors will continue to receive a clinical documentation query. All Mater medical officers, including VMOs and registrars, are asked to respond to these queries within two days. Where a response is not received within this timeframe, the clinical documentation queries will be passed on to the Medical Lead of the relevant clinical stream.

A fact sheet is available for more information on how you will receive documentation queries, and how you can respond.  A previous article about clinical documentation and coding improvements also provides some background to this project.

While this process has proven an effective way of clarifying gaps in clinical documentation, our preference is to work with doctors at the time of the patient’s admission to ensure documentation is specific and complete. To help achieve this, we have commenced a number of initiatives aimed at enhancing clinical documentation and coding knowledge on the ward to assist doctors to document specifically and completely during the patient’s admission.

A Clinical Documentation Advisor, Andrea Whitehead has also recently commenced and will work alongside clinicians and the clinical coding team to assist in improving the quality and specificity of clinical documentation.

There are also a number of support materials available including specialty-specific ‘Clinical Documentation Guides.’

Both the query process and current work being completed to improve our clinical documentation is resulting in improved outcomes for Mater and ensuring we are contributing to Mater’s commitment to the provision of safe, low-variability, evidence-based healthcare.

For further information, please contact Andrea Whitehead (Clinical Documentation Advisor) on 07 3163 6554 or [email protected], or Lisette Ramsden (Manager Clinical Coding Service) on 07 3163 5829 or [email protected].