Who is responsible for writing and maintaining clinical documentation + other common questions

What is clinical documentation: An overview

Clinical documentation refers to the production of digital records related to patient healthcare. It is an essential component of all healthcare businesses and their medical practice management systems.

Medical information may include data concerning a patient's symptoms, medication, history, treatment, medical records, tests, and any other assessments. It serves as an effective point of reference for evaluation and consultation among different healthcare providers to deliver the highest level of patient care.

Clinical documentation formats can be both paper and electronic; however, due to their ease of use and high level of interoperability, the electronic health record system is the leading option for healthcare professionals. In fact, over 100 million medical professionals in the US use clinical documentation and incorporate some electronic components.

With additional clinical documentation improvement practices in place, your healthcare business can ensure that implementation is successful and reaps continuous benefits for physicians and patients.

What are the benefits of maintaining clinical documentation?

Poor documentation can lead to misinterpretations and errors in patient care. It can be stressful to always attend to records, ensure they are accurate, and correctly represent patient history. In contrast, there are many advantages to implementing and maintaining clinical documentation within your healthcare practice, as having effective clinical record management can greatly elevate patient satisfaction and the overall quality of your service.

Using electronic clinical documentation is an excellent way to regulate patient files and organize them in a way that is easily accessible. These systems present various other benefits, including:

• Increased revenue: Good clinical documentation allows for better medical billing and coding processes, which lead to accurate reimbursement and fewer errors on insurance claims.
• Fewer delays: With more accurate information and billing processes, financial reimbursements are less likely to be delayed. 
• Identifying risks: Clinical documentation systems can help identify critical values in lab results or examinations, which can increase the efficacy of treatments and assessment plans and thereby enhance patient safety.
• HIPAA-compliance: Using clinical documents allows you to comply with HIPAA regulations by having accurate and up-to-date information that is held private. You can relax knowing your patient data is secure and at minimal risk of jeopardy from hackers. 

Who is responsible for writing & maintaining clinical documentation?

Clinical documentation and medical records are composed by the physician to ensure that patient needs are accurately documented in the context of professional health. Because various healthcare providers and insurance companies refer to these clinical notes, they need to be authoritative to emphasize their credibility. As such, healthcare professionals should produce the documents in direct response to interactions with patients, and the content should provide a professional opinion with clear expertise. 

On the other hand, clinical documents do not necessarily have to be maintained by healthcare physicians as this can be done by authorized healthcare personnel. They should not add or alter the documents, as they may not have the medical training or certifications to make direct edits. However, they can verify the information to ensure it is accurate. For instance, staff may be responsible for storing the data and transferring it to other healthcare and insurance providers if needed.

What are the basic duties of physicians who manage medical records?

For the many physicians who manage client documentation, there are some basic duties they must take under their belt to ensure that the notes are up to standard and stored securely. This includes duties such as:

• Restricted access: Physicians need to ensure that only authorized users have access to the relevant information. This is understandable, considering that everyone has different roles within healthcare organizations, so patient records do not need to be accessed by all. 
• Storage efficiency: In accordance with local and international laws, you need to determine how long you keep medical records in storage. Information is only retained for a certain amount of time before it is appropriately destroyed. 
• Easy patient access: Patient records should be able to be accessed by the patient upon request, as well as to the succeeding physician, in the case that the current one resigns from their practice. You also cannot refuse record transfers on the part of the patient at any point in time. 
• Charge the right fees: If there is an incurring cost for the transfer or retrieval of medical information, the patient, or another authorized individual, needs to be charged the correct amount. 
• Educate patients: Your job as a physician is to ensure that all patients know how to access medical records and notify them concerning how long the record is available. Doing so gives patients more control over their role in healthcare and supports autonomy over their private information.
• Destroy records accordingly: As clinical documents are not kept forever, you must implement the right destruction processes to ensure that confidentiality is maintained. 

What are the common confidentiality and data protection measures to follow while managing patient records?

There are various protection measures that you can implement to ensure patient records are kept private and confidential, which all contribute to a high-quality service that prioritizes patient needs. Some common confidentiality and data securement measures include the following:

Restricted access

Patient data and information must only be shared with those who have authorized access to the specific data. This prevents information from being leaked and unauthorized edits and modification of information, which breaches numerous HIPAA regulations.

Implementing strong password management policies ensures that only authorized users can access sensitive patient data. Passwords should be complex, changed regularly, and not reused across multiple accounts.

Secure data transfer

Information must be transferred through acceptable channels that are highly secure. This means data cannot be shared through Gmail, Dropbox, iCloud, or other non-encrypted services, and it is forbidden to share any information, even pictures, that can be easily identified through social media platforms.

To ensure the secure transfer of patient data, consider the following measures:

• Use of secure protocols: Transfer data using secure protocols such as HTTPS, SFTP, or FTPS. These protocols encrypt the data during transmission, protecting it from interception.
• VPN for remote access: When accessing patient data remotely, use a Virtual Private Network (VPN) to create a secure, encrypted connection to your healthcare network.
• Email encryption: If email is used to communicate sensitive information, employ email encryption solutions to protect the contents of the email during transit.
• Secure file-sharing services: Utilize secure file-sharing services that offer end-to-end encryption for transferring files. Avoid using non-encrypted services like Gmail, Dropbox, or iCloud to share patient data. 

Security measures

To strengthen cybersecurity defenses against potential hacks, various technical measures can be installed and integrated into your healthcare business. These include:

• Anti-virus software: Install reputable anti-virus software on all devices used in your healthcare facility. Regularly update the software to protect against the latest threats. Configure the software to perform automatic scans and to quarantine or remove any detected malware.
• Firewalls: Set up firewalls as a barrier between your internal network and external threats. Ensure that the firewall rules are configured to allow only necessary traffic and to block suspicious or unauthorized access.
• Encrypted servers: Store patient data on servers that use encryption to protect the information. Ensure that the encryption is up to date and uses strong encryption algorithms. Regularly review and update encryption keys to maintain security.
• Breach monitoring services: As an additional measure, you can use breach monitoring services such as Breachsense to check if any staff email addresses or account details have been exposed in a data breach. This can help identify compromised accounts early and take necessary actions such as changing passwords or implementing additional security measures.

Additionally, provide training for your staff to ensure they know these protocols and how to efficiently handle sensitive patient data. Regularly review and update security measures to adapt to evolving cybersecurity threats.

Who is a clinical documentation specialist, and what are their basic duties?

Often, it may be easier to hire a documentation specialist who specifically deals with clinical document management and extensively understands how to organize patient information. These specialists can improve clinical documentation processes, ensure that businesses comply with HIPAA requirements, and work towards aligning medical provider and patient treatment information. They may also oversee medical billing and coding processes to check whether they have been entered and applied correctly and conduct general analyses concerning patient health records.

Clinical documentation specialists have excellent organizational and communication skills to identify inaccurate information. They ensure that all collected data is detailed and accurate to the specific patient. This may entail going through the files and every line of medical code to assess and pick out any blanks, as well as following up on any answered queries or delays.

The specialists may communicate with insurance companies to ensure that the right medical reimbursement has been awarded and with physicians to ensure their office is stating the correct claims processes. The healthcare professional uploads Any issues or queries into the system, while the specialist spends a lot of time double-checking, verifying, confirming, and authenticating patient information.  

Final thoughts

Clinical documentation is a broad component of all healthcare businesses and is essential to the smooth operations of a clinic and vital to the patient healthcare experience. Composing, maintaining, and organizing clinical documents are all non-negotiable aspects of healthcare businesses, and being able to incorporate medical record management effectively will help drive your business to success.

All in all, patient data should be secure, up-to-date, and easily accessible; healthcare platforms, such as Carepatron, efficiently support such requirements and even offer speech recognition software and AI transcription. With software like this, you can compose clinical documents using templates and resources and store them securely in HIPAA-certified encrypted servers. It’s a win-win for all involved, and will greatly elevate the quality of your service, so get behind it!