Five Popular Clinical Documentation Audit Tools

Clinical documentation is the need of the hour today and it is used by the health care industry to assess the quality and standard of the patients. Here we discuss dome of the popular tools used in this process.

The primary focus of having clinical documentation in the health care industry is to monitor the quality and standard of the medical care that is provided to the patients. Responsibility of maintaining high standards and quality in the treatment process as well as accountability and responsibility to provide the best available medical resources is directly associated with clinical governance. Clinical audit is the main feature of clinical governance and it is done to maintain clarity and review performance, which automatically helps to improve the medical documentation procedure. Thus, clinical documentation plays a crucial role in the medical field.

The primary audit tool that is required for effective clinical documentation is the “Out of Hours Toolkit.” This tool was designed and developed by the Royal College of General Practitioners. The primary purpose of this tool is to perform out of hours services audits. It follows a fixed set of parameters for physicians, call receivers, treatment process, and patient handling. It provides results in point rate grading system to measure whether the patients’ needs were met or not i.e. it measures the output of each and every personnel. It includes rating scale from 0 to 2, where 0 indicates that the needs of the patient were not met, 1 indicates they were partially met and 2 indicates fully met.

Another important clinical documentation audit tool is the “IMRCI – Back Pain Audit Toolkit.” It was developed keeping in mind four crucial areas- exercise, active lifestyle, manipulation, and bed rest. The assessment done by this tool mainly focuses on initial diagnosis, psychosocial factors, treatment investigation, and medication. There have been several drawbacks of this tool because it focuses mainly on the initial visit and does not consider the whole treatment process. Treatment details reviewing place is absent, and there are no back pain audit standards set in the tool.

The clinical documentation software from Sigmund is a fully computerized system. It helps in maintaining records or documentation from the stage of admission to the discharge of a patient. It includes effective tools, which monitor accuracy, quality, and documentation time. It has e-signature, and automatic assessment of documents and task management, which streamline the process of documentation by reducing the patients’ waiting time and increasing the output level.

The Concerto Orion clinical documentation software helps in the improvement of quality and accuracy. It maintains accurate documentation, which is based on HER and includes customizable templates. It is a great tool for audit and is widely used by health care industry professionals. Another prominent tool is the CdiTrax, which is also great documentation software in use nowadays.