CLINICAL DOCUMENTATION SERVICES
Clinical Documentation Services
Medical billing and coding staffs for health care providers use clinical documentation when evaluating claims. Most healthcare facilities employ clinical document improvement (CDI) specialists to review each patient’s clinical documentation and ensure it is comprehensive to ensure there are no gaps in a patient’s clinical documentation. Clinical documentation improvement systems (CDIS) also help to improve the accuracy of clinical documentation.
Clinical Documentation Services We Offer
Our transcriptionists have years of experience transcribing all kinds of medical reports, including medical histories, physical examination reports, operative reports, discharge summaries, emergency room reports, chart notes, medical evaluations, psychiatric evaluations, and x-ray reports.
Utilizing a medical scribe allows for real-time documentation and 100% completion of charts same day of service. In addition to reducing chart closure times, the medical scribe creates the capacity to see more patients during the day and improve the time spent during the patient visit.
Benefits of Clinical Documentation
- Reduced Claim Denials
- Decreased Physician Queries
- Accurate Coding
- Improved Quality Patient Care
- Better Communication