The Importance of Clinical Documentation in an Acute Care Facility

The main intention of this paper is to justify the need for a clinical documentation program and a clinical documentation specialist within an acute care facility. The research involved in the creation of this paper was done through the use of articles, journals and internet searches. This research assisted in justifying the rationale that a clinical documentation program can benefit a facility in many positive ways. The paper explains the method necessary to accomplish this goal, including the educational benefit the clinical documentation specialist and program can offer facility physicians and clinicians. It will address how through the implementation of this type of program a facility can improve their clinical documentation which in turn will result in improved patient care and enhance a facilities revenue cycle. The paper will address the role of the clinical documentation specialist, issues with physician resistance and other topics such as clinical documentation in regards to CMS Recovery Audit Contractors (RAC). The transition and evolution of clinical documentation from manual charts to the electronic health record will also be reviewed. The project includes a diagram explaining the role of the clinical documentation specialist, a job description for the position and a training matrix explaining the type of training involved.