How to Use Modern Clinical Documentation Methods to Measure Surgical Outcomes

Clinical documentation.When it comes to clinical documentation, surgeons rely upon complete and timely reports for the purpose of measuring surgical outcomes. Years ago, there were many obstacles that stood in the way, which meant several delays in proper patient care were often the norm. However, through the emergence of electronic medical records as well as modern clinical documentation methods, such as synoptic reporting, surgeons are able to improve their medical outcomes dramatically for a variety of reasons.

Eliminate Medical Transcription

In the “good old days,” just about every physician or medical facility employed a transcription department. As time went on, the trend shifted more toward outsourcing transcription as a way to cut costs, but even that method wasn’t as efficient as administrators and clinicians would have liked it to be.

Using modern clinical documentation methods means taking advantage of some of the great technological advances healthcare professionals have available to them. Synoptic reporting is an excellent example because surgeons or staff members are able to input the needed data during the patient encounter. That means there is no need for any type of transcription team, and patient reports are available immediately.

Use a Template for Creating Surgical Reports

One of the issues that researchers, medical staff and physicians have historically had with patient reports is the fact that it’s difficult to use them to support any research into determining medical outcomes. Quite often, patient information varies from patient to patient; even patients who carry the same or very similar diagnoses.

When the required patient data is missing from reports, it can create a lot of problems with the patient’s treatment plan, as well as later one when attempting to gather information to determine medical outcomes. By using a template and streamlining the medical terminology that’s being used to complete the report, understanding medical outcomes is easy, and it makes patient reports much more meaningful.

Cross-Reference Patient Data

Over time, all surgeons want to conduct retrospective research to find out how effective their treatment plans are, and how they can make changes that will improve them. Old-fashioned clinical documentation methods can make that type of research nearly impossible. However, synoptic reporting offers researchers the ability to take advantage of the search function that’s built into the system. The search function allows them to look at a variety of patients and compare and contrast them easily. They can come to the appropriate conclusions in much less time, and with far more accuracy than with older research methods. As a result, patient care is not only improved in the short term, but it’s improved in the long term as well.