Clinical Representation System: Clinical Documentation System

Decent Essays
Assignment #1
Stakeholder: VP of Nursing
System: Clinical Documentation System

Over the past decade there have been many advances in software that provide advantages for clinical documentation. Clinical documentation is at the core of every healthcare encounter and current legislation dictates that it must be accurate and complete. If clinical documentation does not adequately and precisely reflect the treatment and outcome of each encounter, the actual quality of care that was delivered could be seen as irrelevant. With changes to the way healthcare is funded, clinical documentation, or the resultant data and information extracted from that documentation, is how providers and organizations are being measured and adjudicated. (Jamal, 2014)
Benefits
There are many benefits to be gained from the implementation of a new clinical documentation system but essentially they can all
…show more content…
high quality documentation are included below as illustrations of the difference, including the impact on RIW calculation and potential funding implications (Jamal, 2014)
Risks
The largest risk associated with a system implementation of this type is Change Management. A change management frame work and tools will need to be in place to address how to create a shared need for the change, understand and manage resistance from key stakeholders and build effective influence strategies for change. For this to be successful there must be authentic, committed leadership visible to everyone in the organization throughout the duration of the initiative. (Detwiller, June 2014)
Challenges
Several challenges have been identified associated with a clinical documentation system implementation. Based on the literature, there are ways to mitigate the risk associated with these challenges.
• Clinician Engagement and Adoption
• Human Resource Issues o Availability of Employees o Availability of Required Skill Sets
• Education & Training

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