Standard Clinical Documentation Terminology

Most healthcare professionals are well aware that the purpose of clinical documentation is to closely track and communicate patients’ medical conditions (diagnosis, treatment plans, etc.). However, it’s important to recognize that the clinical documentation process has changed over the years from its role of serving the needs of patients to include the needs of healthcare providers. With these changes in mind, there has been a movement to implement terminology standardization in order to make clinical documentation more efficient and effective.

Here are some of the positive outcomes that standardized terminology can provide:

  • Better record-keeping of clinical details over long periods of time (problems, interventions, outcomes); this improves patient care, as well as supports research efforts
  • Shared understanding of medical terms across the continuum of care (improved communication among different clinicians, different sites of care, different languages and different systems)
  • Ability to identify and monitor health trends and outcomes on a large scale by pooling data from multiple sources
  • Ability to audit quality of services and benchmark results
  • Ability to identify individuals in need of proactive medical intervention

In essence, standardized terminology streamlines the clinical documentation process to ensure an integration of evidence-based guidelines and better quality measurement. With improved clinical documentation practices, healthcare providers are better equipped to ensure the most optimal patient outcomes and accurate medical records across health systems.

Is your organization using standardized terminology?   

Get in touch today with MedPartners and make sure your team is trained on the best clinical documentation practices.


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