White Paper

Addressing The Documentation Challenge For Clinicians

Source: Health Language
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Clinicians should consider deploying a workflow enhancing search solution that ensures problems, procedures, and diagnoses are properly documented and mapped to standards. This approach not only improves the quality of clinical documentation, but also increases clinician productivity and satisfaction–all critical goals when promoting the adoption of standards such as SNOMED CT and ICD-10.

Healthcare providers are rapidly converting from the paper chart to the Electronic Heath Record (EHR), driven steadily by the Meaningful Use initiatives.

The haphazard problem lists maintained in the paper chart are being replaced with codified problem lists that will improve interoperability and decision support, while also providing a concise understanding of the patient’s conditions. To support Meaningful Use, clinicians will need to create SNOMED CT®-encoded problem lists and ensure accurate ICD-10-CM diagnosis codes. The proper coding of these problem lists would become a cumbersome endeavor if clinicians had to know the underlying complexity of SNOMED CT and ICD-10.