Importance of Documentation in Healthcare | Lightning Step

The importance of complete medical records in healthcare organizations has always been clear, but never more than now with the added pressure of the pandemic on the healthcare system in general. Medical documentation provides a full picture of a patient’s medical history, in order for clinicians to have all the information they need to consider when treating or diagnosing a patient. If this information is incorrectly documented, illegible or unnecessarily delayed, it can cause immense risk to the patient in question. Good documentation provides patient safety and quality of care. It is extremely important that healthcare organizations put time, effort and resources into ensuring that their documentation practices meet high quality standards. 

The Human Cost of Poor Documentation Practices

• Poor documentation in healthcare causes processing delays. An hour of documentation delay is an extra hour that a person in vital need of care isn’t getting it.
• According to a report from CRICO Strategies, communication problems were a contributing factor in 30% of malpractice claims filed between 2009 – 2013. 
• It opens up the risk of poor treatment decisions. If the clinician or healthcare provider does not have an accurate documentation of the patient’s treatment history, then incorrect treatment decisions can be made.

3 Benefits of Proper Healthcare Documentation

1. Efficient clinician and healthcare personnel communication: Healthcare documentation is the most efficient way for clinicians to communicate the patient’s story, what they were suffering with and how it was treated, which in turn helps any future clinicians or medical teams to evaluate a patient’s treatment plan. It also acts as a record for continuity of care, regardless of the type of medical treatment.
2. Correct and timely reimbursement: In order for reimbursement to be processed in a timely manner, the healthcare documentation backing up the billing needs to be complete and accurate. If the documents are sub-par or missing vital information about the patient’s treatment, for example not documenting why certain tests were requested or completed, then it can cause unnecessary delays and possibly even denial of reimbursements.
3. Patient safety: Accurate documentation reduces any risk exposure to patients and healthcare organizations and ensures that the patient gets the appropriate care when they need it. Good clinical records also audit the quality of the healthcare services offered and can be used for investigating any serious incidents in the patient’s care. Patient safety and protection should always be the top priority.

How Lightning Step Can Make Your Medical Documentation More Efficient

With an RCM that is fully integrated with its EMR, like Lightning Step’s is, all information collected during patient intake to perform a verification of benefits will carry over to the EMR and RCM. With non-integrated systems, the same information must be manually re-entered into multiple systems. The threaded architecture of Lightning Step allows you to avoid the error-prone and time-consuming manual data entry process, from pre-admission screening to discharge, your data remains clean and connected.

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Here at Lightning Step, our team is comprised of professionals that have dedicated their lives to addiction and mental health treatment. Our EMR is built specifically for addiction and mental health treatment by clinicians and Joint Commission experts, our cutting-edge platform for medical records saves you more time for your patients. One reason we are passionate about bringing Lightning Step to your facility is this: documentation saves lives. We understand the importance of complete medical records that are designed to meet CARF and Joint Commission standards, and every professional in the fight against addiction knows that longer treatment episodes are linked to better outcomes. That’s why Lightning Step has been built to prompt best practices in documentation, because when it comes to getting days for treatment authorized and paid by third party payers, documentation rules the day.

We have dedicated staff members that keep up to date with the changes in documentation compliance and ensure that Lightning Step meets those requirements through regular updates to the software. We are constantly in contact with our clients and value their feedback as it helps us to provide a better, more compliant product. Not only does Lightning Step work hard to maintain compliance but the software also allows for several ways to track and audit compliance in an efficient manner.

Erin McDaniel, CARF Reviewer

Lightning Step takes the guesswork out of documenting to managed care companies by automatically formatting your notes with the pertinent clinical information needed by third party payers. Our intake assessments are specially designed to capture the medical necessity criteria required by managed care companies to authorize reimbursement, our utilization review tools guide your clinicians in writing the perfect progress note, and our intelligent UR dashboard puts all the case information you need at your fingertips to ensure that insurance companies authorize the maximum amount of treatment days your client needs.

You are in the business of saving lives. We are in the business of helping you do it, by providing efficient and accurate documentation best practice and processes to your organization.