Clinical Documentation: Striving for Continuity of Care

Clinical documentation plays a crucial role in patient care by ensuring continuity, facilitating billing, and providing legal protection. However, secondary goals like billing and liability protection can detract from the primary goal of quality care. Solution: decouple secondary goals from the documentation process by using transcripts for legal purposes and NLP for coding, allowing clinicians to focus on continuity of care by writing concise SOAP notes. Emphasis should be placed on continuity of care without excessive paperwork.

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Importance of Clinical Documentation in Patient Care

Clinical documentation plays a crucial role in the delivery of patient care, serving as a cornerstone in the healthcare system. It not only ensures the continuity of care, but also facilitates the billing process and provides a shield against professional liability. While many see these goals as interconnected, the two latter goals can detract from the primary objective of providing the best possible care for the patient.

Continuity of Care as the Primary Goal

Continuity of care, or ensuring that all members of the healthcare team have accurate and up-to-date information about a patient’s condition and treatment, should be considered the most important goal of clinical documentation. By providing a complete and accurate record of the patient’s care, documentation helps to ensure that the patient receives consistent, high-quality care as they move between different healthcare providers.

Billing and professional liability protection, while also important, could be seen as secondary goals. Billing based on the documentation of the care provided is necessary to ensure that the clinician or organization is paid for the services they provide, while legal documentation can provide protection against malpractice claims. However, these goals can lead to overly bureaucratic and time-consuming documentation processes that distract from the primary goal of providing quality care.

Enhancing the Clinical Documentation Process

To enhance the clinical documentation process, one potential solution is to separate its secondary objectives from its primary goal. This could be achieved by utilizing a transcript of the visit for legal purposes and employing natural language processing to identify the necessary codes for billing and coding. In this way, healthcare providers can concentrate solely on the primary goal of delivering continuity of care to patients. By writing a concise SOAP note, clinicians can focus on providing high-quality patient care.

One potential solution is to decouple these secondary goals from the clinical documentation process. For example, an actual transcription of the visit could be used for legal purposes, while natural language processing (NLP) can be used to identify CPT and ICD-10 codes. This could allow clinicians to focus on the primary goal of continuity of care. I, for one, would love just needing to write a concise SOAP note to document patient care. That’s what doctors did for years when writing a short note on an index card.

The Importance of Focusing on Continuity of Care

While clinical documentation serves multiple purposes, it is important to remember that the primary goal of clinical documentation is to ensure continuity of care for the patient. By focusing on this goal, we can ensure patients receive the best possible care, without being burdened by overly bureaucratic and time-consuming documentation processes.

In conclusion, the need for clinical documentation is not just limited to providing continuity of care, but also serves as a source for billing and legal purposes. However, these secondary goals can often lead to overly bureaucratic and time-consuming documentation processes, detracting from the primary objective of providing quality care. 

Instead of relying on technology to solve a problem created by bureaucracy, it is important to address the root cause by decoupling the secondary goals from the clinical documentation process. By focusing on the primary goal of continuity of care, we can provide patients with consistent and high-quality care, without being bogged down by excessive paperwork. 

The solution could be to have a separate process for billing and legal purposes, while allowing clinicians to focus on documenting patient care in a concise and simple manner, ensuring that the continuity of care is maintained and the patient receives the best possible care. 



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This article was generated with the help of GPT-3. Image was created with the assistance of DALL·E 2.

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