Misinterpretation of language leads to several issues impeding physicians' ability to administer quality care. Anthony Oliva, MD, explains why healthcare professionals must speak a unified language to ensure optimal care for patients.
Here are five notes:
1. Notes pertaining to patients' conditions are unclear or buried in charts, creating problems for patients, revenue and predicting risks. While physicians communicate a wealth of information in a fast-paced manner, this system does not always work and creates an atmosphere of confusion among healthcare workers.
2. Physicians' diction differs from the coding language necessary for billing and hospital payments. A Clinical Documentation Improvement program should be utilized to ensure better translation of what physicians say into coding language.
3. A discrepancy often exists in a patient's perceived and actual health due to sparse clinical documentation forgoing specific details on a patient's health. Conditions often do not get translated into co-morbidities or diagnosis codes in a record. Thus, a patient will receive insufficient and often incorrect treatment to amend serious conditions.
4. Patient health will be nearly impossible to predict if charts do not accurately reflect a patient's actual condition or the conditions a physician treats in his/her community. Predictive modeling needs accurate clinical documentation, starting with physicians.
5. Healthcare professionals must pay close attention to what physicians say to help physicians translate what they do into the appropriate documentation. Administered care must be accurately reflected on a chart that all professionals understand to provide the best possible care for patients.
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