Clinical Documentation Improvement Is At The Backs The Medical Industry

A hospital is not just a place where doctors work. Of course, they make up for most of it, but there are many support staff working in the background: the nurses, the janitors, the data managers, the administration, and the medical coding consultant. People usually don't know what a medical coding consultant does, but it is an important and well-paying job.

What Does A Medical Coding Consultant Do?

When you visit the doctor, post the OPD, s/he writes a prescription and something in your patient file. Now, they can't keep writing the significant complicated medical terms per their busy schedule. All the records written by doctors are in shorthand. What happens after it is where a medical coding consultant comes into the picture. They are responsible for converting these shorthands into legible, understandable words and filing them. Apart from this, they also review medical bills, keep a tab on patient charts, and are responsible for making insurance-friendly documents for reimbursements of the treatment. This may sound like a lot of grunt work, but it is of utmost importance in the medical field.

The patient data stored by the coding consultant is then sent to a medical record review company.

What Is The Importance Of A Medical Record Review Company?

Let us go back to the most beloved doctor's show on earth, ABC's Grey's Anatomy. One of the most common practices seen in this show is that the doctors hold a roundtable conference in complicated cases to derive the best treatment option for the patient. In the real world, this is done by a medical record review company. They study the patient's history and current medical records to deduce the best treatment procedure for the patient, helping doctors save a lot of time and focus mainly on administering the treatment. Along with this, they are also responsible for clinical documentation improvement.

What Is Clinical Documentation Improvement?

Clinical documentation improvement or CDI is one of the medical institutions' most critical support systems. Based on the empirical evidence (patient records), the improvement of clinical documentation reviews disease patterns, disease processes, and diagnostic findings. They also check personal patient charts to see if it is missing something. If so, they report it straight back to the medical coding consultant and know that it has been rectified.

Why Is There A Need For CDI?

With the advent of technology, medical records have become digitized. All the data we're now stored in Electronic Health Record (EHR) format. But innovations come with their own set of challenges. Despite being a centralized system, filing medical records differed from consultant to consultant. This led to many discrepancies in the records and was very problematic for both the hospital and insurance companies to understand the EHR. It became quite a burden to translate the data into the formats asked. Hence clinical documentation improvement was set up as a system of checks to ensure no such discrepancies occurred. And they give a timely report to the medical coding consultant about their method of filing, thus making the whole system a streamlined process.

No Job Is Low In The Healthcare Sector

So next time you see someone dejected about not getting into a medical college, remind them that they can still contribute to the healthcare system without being a doctor. Despite being secondary and tertiary medical institutions, these services are essential. So much so that eliminating them might lead to crippling the whole healthcare system. They are part and parcel of the medical innovations taking place every day. They are the backbone of the medical institution.