Clinical Documentation Review and Redesign

Whether using paper or electronic medical records, agencies are faced with the challenge of finding a balance between collecting necessary patient information without overwhelming clinicians with unnecessary or duplicative documentation. The development of concise, evidence-based documentation, in support of regulatory requirements, is critical to providing exceptional care and defending practices under increased payor scrutiny. By analyzing an organization’s current documentation while considering survey trends and outcomes, BlackTree’s clinical consultants can assist by redesigning templates and forms to assist in the capture of necessary data to support both regulatory requirements and quality patient care.