Clinical documentation carry important information about the patient. It is essential that their is standardized way to produce them to enhance readability and reduce errors. This article talks about one such standardization i.e. the C's.
Clinical documentation is a combination of multiple medical records. They serve the most important purpose of recording the treatment given to patients. In a hospital, it is essential to record these documents because of its scientific and legal significance.
Medical records are often used for research purposes and also helps the government to establish proper policies and strategies for the general well being of the people. Other than that, they are also preserved for any legal obligation that might occur in the future.
In all of this, the five C’s used in clinical documentation plays a critical role while recording documents. This article deals with the subject of 5 C's: what are they, their importance, and plausible solutions to boost their productivity.
Errors within the medical records in the community are recurring issues. These generally occur because of cognitive overload and overwork in the healthcare sector. It is because hospitals witness hundreds and thousands of patients (depending upon the scale of the hospital) on a daily basis. This is overburdening to the practitioners and often leads to confusion while filing documents.
This is for the same reason the 5 C’s of clinical documentation came into being. Practicing these C’s while documentation reduces the chances of errors and misunderstandings to an exponential low. Moreover, these C’s help in standardizing the work making the overall workflow of recording clinical documentation much more productive.
Clarity is one of the most essential components of clinical documentation. Medical records possess a variety of data points that includes multiple medical terminologies and standardized abbreviations. It is essential to write those data points correctly because otherwise it would end-up misconstruing the total meaning of the record. Aside from that, it is also essential to use proper grammar and spellings in the medical record for the reason mentioned above.
Medical records should be created in a manner that they are easily digestible to everyone who reads them. Conciseness is another important factor in a medical record that helps with making sure that the medical records are easy to read. Also, the information provided in the medical should be as brief as possible. There should be notes to make things more clear. Yet, the core intention while creating a medical record should be to keep it as short as possible. It will also help in reducing the workload during medical recording.
People working in the hospitals work meticulously with one patient to another. Post this, there are multiple entries that are created within the registry. It is essential that each of these entries are completed during the time of caregiving. It has been witnessed that a lot of employees in hospitals end-up leaving blank spaces for entering the data later on. However with so many patients requiring urgent care, the chances of messing up the registry are much higher. Therefore, the easiest way to keep an accurate medical record is filling in the data real time with proper completeness.
Medical records are ideally called the property of the hospital. However, it is still a confidential document that can’t be shared without the proper authorization of the patient to any third party. Therefore, it is essential for the clinics to adhere to the confidentiality of the medical record. It is also a mandate because of the HIPAA standards.
A medical record isn’t easily readable or scannable by any person, if it is not mentioned chronologically. A medical record is a treatment given to a patient that comes in a series of steps taken one after the other. A great analogy to explain this would be that mentioning the surgery before anesthesia wouldn’t make sense in the medical record. Also as we discussed hospitals deal with so many patients at one go that messing up the chronology would create furthermore confusion later on.
One other great reason for keeping the chronology intact is its importance during court trials. Post providing care, hospitals are always prone to outcomes that are not always favorable for the patient. In situations such as this, accusations can be made on the hospitals. Therefore keeping the chronology intact helps immensely during times such as this. The medical record would show what all treatment was given to the patient and would help the hospitals justify that they provided the best care considering the situation.
About VisionERA: VisionERA is an intelligent document processing platform. It is capable of providing processed information from raw unstructured documents and feeds it directly to the EHRs. It is easily moldable because it allows the user to create its own workflow and provides automated capabilities for document processing operations such as data extraction, data validation, application of business rules, etc. With VisionERA, hospitals can automate any of their document processing use cases end-to-end.
Hospitals are rapidly converting their document processing infrastructure to digital. Yet, there are still multiple places where the papers are used. These papers are either manually fed to the EHR system, or their scanned copies are saved into the system, or both. VisionERA can automatically extract data from them, verify them (if the functionality is required), and store them directly into the EHR. This entire process happens with minimal manual intervention in the beginning and later on the system learns the process by itself.
The concept of the 5 C’s might look simplified but their application enhances the quality of the clinical documentation. It is essential that clinics maintain these strategies and employ systems that allow them to use the 5 C’s in a more efficient way. VisionERA can’t reduce manual work at every node of the workflow. Yet, it can take out all the redundant document processing work that leads to cognitive overload in doctors and nurses. Adding to it, it can help with various other operations such as manual data entry, audits of old reports, consolidation of data in spreadsheets, and much more.
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