New Research: The Clinical Documentation Challenge The accuracy and completeness of clinical documentation is essential for joined-up, effective and safe delivery of care within a Health Trust. But what measurable impacts do accuracy and completeness of clinical documentation along the care pathway have on patient experience, doctors’ and nurses’ ability to care and on the economics of the Trust?

Why is the research important?

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NUAN–DI–001–01–IG–EN, April 2015

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NHS England Paperless by 2018

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Aligned with these goals, the accuracy and completeness of clinical documentation are essential ingredients for the achievement of integrated, effective, efficient and safe delivery of care.

However, there’s currently no research relevant for the UK healthcare environment that quantifies the impact of clinical documentation on patient care, doctor and nurse efficiency or Trust economics.

The research seeks to understand the clinical process impacts

Methodology

Myriad components & systems Some paper, some electronic

Patient Administration (PAS)

Compliance, Assurance & Legal Defence

Clinical Users:

Secondary Users:

Within clinics, inpatient stay & between multidisciplinary team members

Information for other clinicians Including GP, Community

& allied services

Lab Results

Scans

Reports

Surgical Notes

Treatment & Therapy notes

Nursing notes

Assessments

Clinic Notes

Letters

Radiology

Integrated Efficient

Safe

Using

ProvidingAdding

Coding & Reporting Predictive Analytics & Research Data

1. Map and analyse the flow of clinical information across typical patient care pathways

2. Identify areas most sensitive to clinical document accuracy and completeness

Research Results

1. Discharge and transfer

2. Shift handovers

3. Emergency care records

4. Diagnostic reporting

5. Assessment

6. Outpatient and other clinic notes

Risk Exposure

Fina

ncia

l & P

roce

ss Im

pac

t

1

6

34

5

2

– To other providers: Discharge /Transfer

– To other areas: Assessments, Reporting

– To other shifts: Nursing Notes, Clinical Handover Pharmacy

TTOTransport

Discharge Information Completion

EPM PAS

PAS

HR

EPM

Discharge Letter normally electronic with hardcopy for patients

Example: Extract from Transfer Process of Care Pathway

EPM: Pharmacy e-PrescriptionPAS: Patient Administration

HR: Health Record

This research has been commissioned by Nuance and carried out by specialist research company, Ignetica. To pre-order your copy of the full report, due to release in May 2015 visit www.nuance.co.uk/healthcare or follow us at www.twitter.com/voice4health

Who will find the research useful?Management, Clinical, Data and Governance Leaders in Health Trusts seeking to maximise the return on their EPR and other clinical documentation investments.

Will provide Trusts with business value performance indicators for accuracy and completeness of clinical documentation to positively impact:

Patient care pathways

Doctor/nurse productivity

Trust-wide economics

3. Prioritise areas for clinical documentation improvement based on Impact versus Risk

4. Quantify impact on patient care, doctor & nurse efficiency and Trust economics