Clinical Documentation Improvement

Clinical documentation records a medical treatment, medical trial, or clinical test. Enacted by the Health Insurance Portability and Accountability Act (HIPAA), documentation improvement ensures that your patient’s care is properly documented and the services received are accurately reflected. Clinical documentation improvement, or clinical documentation integrity, ensures all providers complete documentation with precision and validity. This is important because your practice needs to know exactly what treatment a patient received before collecting reimbursement from insurance companies. At Zetter HealthCare, we teach providers how to accurately depict a patient’s conditions and diagnoses into the documentation systems. Overall, this accuracy provides the level of care each patient deserves.

During our process, we examine your current clinical documentation and determine inconsistencies and errors. Generally, errors made in clinical documentation are preventable. Usually, illegible handwriting or unavailable patient information is the culprit of these mistakes. However, these mistakes are crucial. One error on a patient’s documentation may seriously damage their health. At Zetter HealthCare, we take care of your clinical documentation and ensure your patients are being given the best care possible.

Another important reason to undergo clinical documentation improvement is so that your healthcare organization remains compliant with the HIPAA. This act is a federal law that sets a standard to protect medical records and other personal health information for patients. HIPAA states that all healthcare organizations must record all patient healthcare correctly and keep it private and secure. Due to this, mistakes in your clinical documentation could result in a HIPAA violation which can incur serious penalties.

For assistance with clinical documentation improvement, contact Zetter HealthCare at (717) 691-6768.