AHIMA July 10, 2020
Documenting in the health record, especially in electronic health records (EHRs), is becoming an increasingly challenging task for many providers across the continuum of care. In recent years, many providers have become burned out and frustrated by EHRs, new reimbursement models, increased regulatory requirements related to quality, onerous query practices, and coding guidelines that vary by healthcare setting.
The purpose of this Practice Brief is to describe documentation best practices and serve as a resource in effective and efficient clinical documentation practices without having a negative impact on patient care. Providers should understand how their clinical documentation translates into data that is used for a variety of purposes.
For many years, providers have struggled with how to document clinical status...
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