Clinical Documentation for Hospitals

Clinical Documentation

Clinical documentation for hospitals is very important. It is defined as the creation of a digital record that details a medical treatment, clinical test, or medical trial. Clinical documents must be timely, accurate, and outline the specific services that were provided to a patient. Often times, they are paired with x-rays, CT scans, MRIs, EKGs, and other records. Keep reading to learn more about the importance of clinical documentation for hospitals.

How Medical Coding and Billing Professionals Use Clinical Documentation

Medical coding and billing professionals depend on clinical documentation to perform their job. Coders evaluate clinical documentation and use the ICD-10 classifications to assign standard codes while billers process claims for services that have been administered by healthcare facilities and are then sent to payers for reimbursement.

Clinical Documentation Improvement

In order to make sure a patient’s clinical documentation is complete and accurate, clinical documentation improvement or CDI is often implemented. The main goal of CDI is to ensure that medical record documentation depicts an accurate picture of a patient’s diagnoses as well as the care provided for their conditions, and the quality of care that was provided. CDI can significantly improve the efficiency of a hospital and reduce the amount of errors, financial losses, and diminished patient care that many hospitals experience.

How Fast Chart Can Help

Fast Chart is pleased to specialize in clinical documentation for hospitals. We offer a single-vendor approach to providing the services, products, resources, and consulting your facility may need to improve your clinical documentation as well as clinical and financial outcomes.

Our highly trained and experienced U.S. based transcriptionists would be happy to help you enhance your existing platform or assist you in implementing our cloud-based platform with your EHR or EMR so that you can upgrade your current clinical documentation system for complete outsourcing.

Our cloud based platform consists of a suite of products to help your health care entity capture, manage, analyze, and distribute documentation in a way that’s more accurate, compliant, and timely. If you opt for our platform, you’ll reap the benefits of Speech Understanding technology which translates typed and spoken words into content that is structured and can easily be interpreted into Clinically Actionable Data (CAD).

Contact Fast Chart Today

If you’re interested learning more about how Fast Chart can improve clinical documentation for hospitals, we encourage you to contact us today. Do not hesitate to give us a call at 919-477-5152 or fill out our convenient online contact form.

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