Clinical documentation systems: another link between technology and quality.

E veryone who works in the healthcare industry grapples with multiple pressures. Organizational leaders and managers face challenges related to delivering high-quality care, ensuring patient safety, reducing costs, and providing exceptional customer service. Professionals, caregivers, and workers alike strive to achieve balance between their professional pursuits and personal lives. In healthcare, technology has not only ushered in sophisticated tools, but it has also improved and complemented existing processes. This positive infusion of technology has caused many stakehold-ers in a healthcare organization to ask, " what can technology do for me? " As the past five installments of this column have declared, the simple answer to that question is, " a lot. " Following the track of the previous installments of this column, the focus here (the last in this series) is on emerging technological advances that promise to maximize the efficiency and effectiveness of one of the most important elements in the delivery of care—clinical documentation. We selected this particular topic to further drive the point that technology, when developed and applied appropriately, is a critical step in improving care quality. t h e t r a d i t i o n a l M e t h o d f o r C a p t u r i n G d a t a Data that come directly from the physician are arguably the most comprehensive and accurate information about a patient. Such data can be used for multiple purposes, including patient care, coding, reimbursement, and compliance. Physicians provide two types of patient information—subjective and objective. Subjective data include progress notes and consultation reports. Objective information, on the other hand, includes physical examination records as well as operative, procedure, laboratory, and imaging reports. Traditionally, a physician dictates notes, reports, and other patient care information into a recorder. That dictation is then sent to a medical transcriptionist to be turned into a written document. However, such a method requires the physician to remember everything and not omit any important aspect of the patient's care and treatment. Under this system, the onus falls heavily on the physician. The reality, however, is that physicians, like other healthcare professionals and providers, are frequently multitasking, are invariably interrupted multiple times during the course Photocopying and distributing this PDF of the Journal of Healthcare Management is prohibited without the permission of Health Administration Press, Chicago, Illinois. For permission, please fax your request to …