The need for accurate clinical documentation

Recently I’ve noticed increased scrutiny of and requirements for clinical data transparency. As a result, hospital administrators are really going to have to start dealing proactively with the issue of accurate documentation (clinical, product, billing, etc.). They’re going to have to look at several factors: OR leadership; the relationships between clinical management, materials management, finance, etc.; patient care processes; materials and supply chain processes; and the technology and information flow (or lack thereof) available to support the necessary changes.

The challenge is that most hospitals seem reluctant to provide the means needed to implement effective documentation solutions. One reason might be because hospital management hasn’t quite caught up to the realities of the situation or because the cost of doing nothing always seemed “affordable.” This kind of short-term thinking can often turn up some pretty heavy consequences in the long term.