Clinical Documentation and Coding: The Fine Brush Strokes of the Patient Picture


You are probably very familiar with the phrase: “If it’s not documented it never happened.” In healthcare you should live by it, because clinical documentation is the core of every patient encounter for every medical institution.

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Accurate and timely documentation is critical for patient care. Not only does it validate and create a clear picture of care provided, but it shares key data with subsequent caregivers and optimizes claims processing. Accurate and up-to-date clinical documentation also aids research facilities, as researchers glean strong data and case study content from documentation.


Clinical documentation is an important bridge between healthcare coders and physicians. It was developed to track a patient’s condition and communicate the author’s actions and thoughts to other members of the care team.


Focusing on clinical documentation and accurate coding ensures a true reflection of patient care provided – not simply the correct words or codes that “pay.” We must not lose sight of the broad impact that clinical documentation and coding have on healthcare. We also need to avoid neglecting the ethical responsibility we all have. It is critical that we ensure medical necessity was truly met according to patient need and that we are not utilizing diagnoses purely to obtain the coverage and medical necessity acceptance. We should not be making or using the EHR (electronic health record) or other technology to lead physicians to a particular diagnosis on the screen or use technology to game the reimbursement system(s). Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexity, new challenges, and in the eyes of some, an increase in inappropriate or even fraudulent documentation.


There are many do’s and don’ts when it comes to clinical documentation and coding that must be followed in order to ensure the healthcare foundation is strong and accurate. Coders and clinical documentation specialists improve the process by helping physicians and other providers refine coding information.


According to AHIMA, clinical documentation specialists do the following:

  • Facilitate and obtain appropriate provider documentation within the health record for clinical conditions and treatment required for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient

  • Exhibit thorough knowledge of clinical documentation requirements as they relate to the classification systems, MS-DRG assignment, and clinical conditions and treatment needs of the patient population

  • Educate members of the patient care team and others regarding documentation guidelines

Successful Clinical Documentation Improvement (CDI) programs facilitate accurate representation of a patient’s clinical status, translated into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.We see the landscape shifting toward more quality metrics, but those metrics are often associated with documentation and coding accuracy and integrity.


The overall goal is to accurately reflect how sick patients are. Patients depend on a complete and accurate medical record. If these patients go to another facility, the clear record, painted by your facility, may be imperative to ensuring a positive outcome.


In the meantime, we must remain diligent in our efforts, engagement, education, compliance, auditing, and monitoring of clinical documentation and coding ensuring it is accurate, complete, and ethical. Coding professionals and clinical documentation improvement specialists should always adhere to the ethical standards established in foundational guidance and rules of the industry.


by Wanda Prada, CPC, CPMA, COSC, CRCR

HIM Coding Manager


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