5 Tips to Improve Healthcare Documentation

Accurate and timely documentation is vital to the success of a healthcare organization, which is why it’s so important to continuously improve healthcare documentation. Improving healthcare documentation reduces costs and improves overall productivity. Many organizations employ a clinical documentation improvement team because the potential time savings are drastic. In order to improve healthcare documentation for your organization, you’ll need to examine the areas that can detract from good documentation.

What is clinical documentation improvement (CDI)?

Clinical documentation improvement is an ongoing effort to improve the accuracy, completeness, and coherency of healthcare documentation. Improving healthcare documentation is a constant process because technological improvements or changes to codes make it necessary to keep up. Also, the communication between coders, healthcare providers, and CDI specialists can always be improved.

Through CDI, healthcare organizations ensure documentation is accurate and accessible for anyone that needs it. It’s about getting every involved party on the same page and minimizing the queries and clarifications that need to occur for documentation to be accurate and complete.

How can healthcare documentation be improved?

1. Assess communication

An important piece of improving healthcare documentation is making sure providers are capturing all critical information. Part of this is ensuring there is no gap in understanding between those documenting and those referring to the documentation. Even if physicians are capturing critical information, it doesn’t amount to much if queries keep coming back.

You must ensure there is proper communication between coders, physicians, and the CDI team at your organization. If issues continue to arise, they need to be resolved.

2. Reduce shorthand

One of the key outcomes of assessing communication between these groups is seeing where miscommunication occurs. This miscommunication can come from unfamiliar or illegible shorthand. Shorthand can cause confusion or inaccuracy, because it only works if both parties recognize and have the same meaning for the shorthand they use. Part of clearing this up is clarifying terms that are written in shorthand or avoiding shorthand altogether.

3. Utilize speech recognition

Due to the time-consuming nature of documentation, incomplete documentation can sometimes pile up and working through a stack of papers at the end of the day often becomes a daily occurrence. This leads to errors or inconsistencies in documentation, but it also eats into a physician’s personal time. Speech recognition can allow physicians to quickly record information with their voice instead of typing information manually.

Fusion Narrate, a cloud-based speech recognition solution built for medical professionals, makes navigating any EMR easier through voice shortcuts and automatic shorthand substitutions. Many healthcare professionals have started using speech recognition to get more out of the initial dictation. In some cases, medical speech recognition software has allowed healthcare companies to reduce or even eliminate transcription spending. Physicians can record dictations directly into healthcare information systems and self-edit.

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Start recording your dictations accurately with our easy-to-use platform, Fusion Narrate.

4. Choose the right EMR

Clerical and administrative tasks are part of a physician’s day-to-day responsibilities, but one thing you can do to minimize the time spent on these tasks is pick the right EMR for your organization. It’s no secret that some EMRs are easier to navigate than others. Check reviews and alternatives, using KLAS or other product comparison websites, to see if you are using an EMR with a high user rating, or if there is an alternative that might better suit your organization. When looking through these reviews, keep an eye out for EMRs that are widely considered to be user-friendly and versatile.

Of course, migration is difficult and time-consuming and as such is not realistic for all organizations. If moving to a new EMR is not an option, consider using Fusion Narrate shortcuts to make navigating the EMR more manageable.

5. Educate your team

If there are dips in productivity related to incomplete, inaccurate, or incoherent documentation, your team may need additional education. It’s important to make sure everyone in your organization is on the same page when it comes to documentation – and for some team members, that might mean relearning fundamentals. Education should be guided by results from assessing communication and reporting. Resolving any miscommunication or confusion in reporting should be a major focal point of education and training. Your team can also enroll in online courses provided by AHIMA or other similar vendors to develop their documentation skills.


It’s important to closely monitor documentation and queries to determine if documentation is becoming a bottleneck. Using the information in this article, you should have a good starting place or some new ideas for improving healthcare documentation at your organization.

Posted by Brian Gaysunas

Marketing Manager

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