Clinical documentation improvement guidelines from ACP

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The American College of Physicians issued an official list of recommendations to improve clinical documentation in hospitals.

1. The purpose of clinical documentation is to enhance communication to support patient care and improve clinical outcomes.

2. Physicians should define the standards for clinical documentation with their organizations.

3. The purpose of EHRs is to facilitate seamless patient care and improve outcomes while collecting data for analysis.

4. Structured data should be collected only where they apply to the delivery of care or to measure quality.

5. Prior authorizations and other documents required by other entities do not need to be unique in data content or format requirements.

6. Giving patients access to progress notes and medical records helps engage them in improving care.

7. Further research to improve accuracy of information, develop tools, improve medical education and spread best practices is needed.

 

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