New clinical documentation education helps clinicians improve skills and patient outcomes

Penn State Health clinicians are invited to learn best practices for patient medical record documentation in a new curriculum now available in Compass. The curriculum offers 2.5 continuing medical education credits and certification. To access the course, launch Compass, then click on this link, or search for “Clinical Documentation Integrity Educational Series.”

The curriculum features an introductory course and condition-based modules where participants will learn how to document accurately, efficiently and comprehensively. Participants can also test their knowledge through interactive questions and examples. After completing the curriculum, clinicians will have a better understanding of the impact of their documentation, Penn State Health’s facility-defined clinical indicators and the fundamentals of the query process.

“Our goal is to align accurate documentation with safe patient care, recognizing that documentation excellence benefits everyone ─ patient, provider and health system,” said Dr. Stephanie Harris, physician advisor of Clinical Documentation Integrity. “In traditional medical education, the focus has been on screening, diagnosing and treating medical conditions, omitting an important component of the medical puzzle, documentation. In addition to being necessary, documentation can also be time-consuming. Taking time to learn how to document efficiently and comprehensively is a good investment.”

Excellent documentation effectively transfers providers’ mental model of the patient into the digital medical record. Communication of conditions with, acuity, specificity and the associated treatments facilitates continuity of care and improved patient outcomes. Provider documentation is also used to calculate Penn State Health quality metrics, including length of stay (LOS), risk of mortality (ROM), patient safety indicators (PSI) and resource consumption (cost). These quality metrics are publicly reported, so accurate documentation is required to reflect the quality of care that we provide at Penn State Health.

For additional resources on clinical documentation, including tip guides, a digital handbook, lunch and learn recordings, Penn State Health’s facility-defined clinical indicators and quarterly newsletters, see Clinical Documentation Integrity on the Infonet homepage under Shared Services.

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