One of the things I end up talking to owners/clinical directors of clinician groups is how to manage clinical documentation standards across the entire practice. When you have an active practice in addition to the oversight of the group it can be a challenge. But if you have provisionally licensed clinicians in your practice, or clinicians with challenges in the area of documentation, its an essential part of the practice.
    Once the structure of good documentation practices in place, there are two big challenges that can negatively impact your group. First, having clinicians not following your basic documentation rules related to content. Second, not completing documentation within the expected timeframes.
    One of the most effective ways to support good clinical documentation is through the implementation of a Clinical Documentation Improvement Plan (CDIP). The goal of a CDIP is to establish a consistent review of documentation at the “pressure points”. 
    You want to make sure that all progress notes are completed in a timely manner? Make sure your practice manager is looking at a report coming out of your EHR where there is currently progress notes missing or not closed – twice a week if you have issues with getting progress notes completed within 48 hours, and once a week on an ongoing basis. 
    Your CDIP should also include a sampling audit completed quarterly. If you have a clinical manager, this may be part of their responsibilities. There are two things that should be the area of focus for these reviews – Completeness and Effectiveness.
    Completeness is easier to understand. You want to make sure your clinicians are not skipping documentation steps. Evaluating these records on a regular basis gives a picture of how they’re doing, and evaluating everyone (including you) adds a level of fairness to the process.
    Effectiveness is around the whole notion of Concise Accuracy. The documentation is not in disagreement with itself. Reviewing records can catch discrepancies or clear inaccuracies within a record.
    An effective CDIP Program can help support clinician accountability in clinical documentation.