Clinical documentation: Easing the burden on physicians

February 28th, 2020 / By L. Gordon Moore, MD

What does “severe” mean? I know this sounds like a specious question, but it provides a window into the complex world of clinical documentation. As a palliative care physician, Dr. Beth Wolf experienced the complexity of communication.  In addition to exploring a person or family’s intentions and wishes with regards to pain or end-of-life care, she saw that the way clinicians communicate with each other was rich with opportunity for misunderstanding.

One pulmonologist used the label “acute respiratory failure” only when patients required mechanical ventilation, another pulmonologist used it any time a patient required oxygen supplementation to keep their O2 saturation above 89 percent.  The same words, but vastly different clinical circumstances.

We use language to convey meaning and in a clinical setting our ability to communicate efficiently and effectively can make a difference to a patient. If I need to treat a person, my understanding of what to do is improved by the degree to which I can quickly discover the exact nature of the problem. Words with ambiguous meaning buried in documentation exploding with cut-and-paste logorrhea make a clinician’s job more difficult.

While some see the work of clinical documentation improvement feeding only the billing department, it also provides a more accurate understanding of a patient’s true burden of illness. Inaccurately representing a patient’s diagnoses can lead to inaccurate numerators in quality reporting, which may lead to quality improvement efforts aimed at fictional issues.

Dr. Wolf explains why she finds joy in the work of helping colleagues improve their clinical documentation. Listen to her describe her journey on the Inside Angle podcast.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.