How Technology Can Augment Clinical Documentation By AGS Health
Clinical documentation has a long history in medicine, dating back to the papyrus records of ancient Egypt nearly 4,000 years ago. This method of clinical documentation, however, was solely for didactic purposes. It wasn't until the twentieth century that the idea of using clinical documentation to improve patient care became systemic. Manual record-keeping is nearly extinct, even though clinical documentation is still essential in healthcare. Electronic health records (EHRs) have allowed physicians and healthcare providers to access a unified source of complete patient information and case histories via various platforms, including smartphones and tablets. The last ten years have unquestionably been the most transformative in terms of clinical documentation. The U.S. Centers for Medicare and Medicaid Services (CMS) sanctioned the 'pay-for-performance' initiative in 2012, marking a watershed moment in healthcare history. This paved the way for the transition from a volume-based model to a value-based care model for the industry. The change, however, has not been easy for healthcare institutions.