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For The Record
E-Newsletter    March 2024
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Editor's E-Note

Clinical documentation integrity is challenging, but new technology is making easier. Learn how artificial intelligence is enhancing documentation and, thus, improving clinical care.

In addition to reading our e-newsletter, be sure to visit For The Record’s website at www.fortherecordmag.com. We welcome your feedback at edit@gvpub.com. Follow For The Record on Facebook and X, formerly known as Twitter, too.

Kate Jackson, editor
In This E-Newsletter
E-News Exclusive

The Evolution of Clinical Documentation

By Keith Loria

Over the past decade, clinical documentation has experienced some meaningful shifts with the advancement of EHRs and artificial intelligence (AI) tools.

“Today, EHRs help capture over 30,000 data points per hospital visit and generative AI is starting to increase that even more,” says Michael Gao, MD, CEO and cofounder of SmarterDx. “To better sort all of this data, clinical documentation has evolved from an individual effort to complex CDI [clinical documentation integrity] teams and processes with multiple roles—auditors, educators, second-level reviewers—and technology and vendor support.”

With these tens of thousands of data points, hospitals now have a more complete picture of the patient journey than ever before.

However, Gao notes, sometimes that picture is more like a jigsaw puzzle.

“All of the pieces are there, but they’re not necessarily assembled in the right order to tell the full, accurate story,” he says. “Templates, structured documentation tools, defined rules, and AI can help process this avalanche of data for CDI teams, so they can make more informed decisions that positively impact patient and financial health.”

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