Changes in Clinical Documentation

Posted on October 8, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

While at AHIMA 2012, I had a chance to sit down with Dr. Jon Elion, Founder and CEO of ChartWise Medical Systems. I asked him about the changes in clinical documentation he’s seeing and I grabbed a video of his answer below. His answer was an interesting and insightful look into clinical documentation and ways that coding is effecting the clinical documentation.

I find Dr. Elion’s answer quite interesting in the terms of using clinical documentation intelligence in EHR. Add in things like coding engines, NLP, and EMR templates and you can see why getting the documentation right is a challenge even in an IT optimized world.