Clinical Documentation – When It’s Good, It’s OK. When It’s Bad, It’s Very Bad.

By April 30, 2021

Written by Monica E. Oss.

Effective clinical documentation has been a challenge for decades. But how does it matter and what can be done about it? A panel of provider organization and health plan experts did a deeper dive during the session, Improving The Quality & Timeliness Of Clinical Documentation: A Best Practices Discussion, at our OPEN MINDS Technology & Analytics Institute last month. We heard from the Mental Health Association of South Central Kansas’ Chief Executive Officer, Mary Jones, and Clinical Liaison, Bailey Blair. The panel included expert perspectives from three OPEN MINDS Senior Associates—Cathy Gilbert (formerly Vice President II, Network Development at Magellan Healthcare and Assistant Vice President of Network Operations at Beacon Health Options); Carol Clayton, Ph.D. (formerly Executive Director for the North Carolina Council of Community Programs and Executive Director for Magellan Behavioral Health); and Lisa Strazzante (formerly Director of Client Engagement and Advocacy for Optum).

Clinical documentation has a ripple effect on services and the bottom line. Documentation (or “paperwork” as some of my clinical friends affectionately call it), is a “necessary evil” of sorts. But good clinical documentation is at the heart of effective quality care, revenue cycle management, risk management, and strong payer relations, according to our panelists.

Documentation that is clear, consistent, complete and reliable enables better clinical decision-making, supports smooth transitions across the continuum of care, and facilitates interoperability and care coordination. In one study, 85% of hospital executives confirmed documented quality improvements within six months of improving clinical documentation (see New Generation CDI Proves Enhanced Patient Care And Reduced Financial Risk, Nuance Leads The End-To-End Coding Performers In The Era Of Big Data, Per Black Book Survey).

In the study noted above, 90% of hospitals that improved clinical documentation said they realized $1.5 million in revenue and claims reimbursement. When notes are completed and reviewed right away, it enables timely billing. But currently, the average time from session to note signing is more than three days, which creates a “revenue cycle vacuum” according to Ms. Jones.

Robust clinical documentation hedges against the risk of recoupment. Post-payment reviews by payers are all too common and documentation has to support what happened. Otherwise provider organizations have to “eat the cost” if the claims are challenged after services have been delivered and employees have been paid, said Ms. Jones.

Building a good track record with quality documentation that clearly establishes medical necessity is key to earning payer trust. Ms. Gilbert explained, “If a provider organization’s documentation is consistently good, payers will pull them off the post-payment review lists, or do fewer reviews.” Documentation is especially critical to justify the level of care provided for higher intensity services, which typically come under scrutiny during the utilization review process.

A problem across all of health care. While a critical function, clinical documentation is considered to be a “problem” across all of the health and human service field. The key challenges? Loss of productivity, not matching payer expectations, and staff turnover.

Clinical professionals are spending inordinate amounts of time on documentation. One study showed that physicians spent 27% of their total time on direct clinical face time with consumers and 49% of their time on EHR and desk work, with many reporting one to two hours of after-hours work on EHR tasks (see Making Your EHR Work For Your Team). And that’s money left on the table. Ms. Blair shared that out of a 40-hour week, most of her clinical professionals are only able to bill 20 hours because they’re spending the other half of their time creating and correcting documentation. She said, “If I was able to get back just eight hours of documentation time for one clinical professional, that’s probably four or more consumers they can add to their caseload. It opens up our program to huge growth.”

Inadequate documentation is also a key reason for challenged claims. Ms. Gilbert observed that she has especially seen issues when payers review higher intensity levels of care. She said, “If the documentation does not support the higher level of care, it impacts revenue for the payer, causes provider organizations to spend more time reprocessing claims, and challenges relationships between the payers and the providers.”

Clinical documentation challenges are often the top reason for staff frustration. As Dr. Clayton noted, “The biggest reason for turnover is dissatisfaction that results from too much time spent on administrivia.” And turnover adds to the burden of training staff and getting them up to speed. Ms. Jones said, “I feel like we’re on a hamster wheel sometimes because of the turnover, which can be as high as 75%—largely due to burnout and not being able to provide services because they are too busy doing the documentation. It’s also devaluing to a staff member when they’re doing great work but can’t write it up in the way that is needed. So it’s that daily effort of train and retrain. And then we’re always bringing in new people and starting the cycle over. And it’s rigorous and very tiring for staff.”

What executives can do to improve the situation. Our panelists suggested some “best practices” to take the pain out of the documentation process—analyze workflows to improve the process, upgrade technology where needed, invest in training and internal reviews, and incentivize staff.

At MHA, notes are reviewed carefully before being sent for billing to ensure that post-payment reviews will not challenge the care provided. They also try to “bill at the lowest level possible” instead of justifying the service levels they are providing, as that results in fewer calls from payers, Ms. Jones explained. It’s also a good idea up front to tie documentation into scorecards and the outcomes data that payers want, especially in value-based reimbursement models, advised Ms. Gilbert.

Technology can play a significant role in improving efficiencies, said Dr. Clayton. Provider organizations can set up their EHR systems to offer appropriate prompts and guide clinical professionals to put in all the requisite information, and help ensure accuracy. “Use the technology to point frontline and clinical staff to what you want them to pay attention to, and that will make it easier for them,” she said. Peter Flick, Chief Executive Officer of Remarkable Health, pointed out the benefits of using artificial intelligence (AI) to drive clinical documentation during a session at the OPEN MINDS Technology & Analytics Institute last month. He said AI can speed data entry with natural language processing, clean up and improve accuracy of the data entered with contextually appropriate tools, and even make recommendations to accurately describe and evaluate service levels. A well-structured, tech-enabled documentation system can also mentor clinical professionals in real time, improving accuracy and streamlining claims submissions.

Ms. Gilbert advised that clinical professionals must be well trained to document for medical necessity and create notes that are “concise, factual, and still tell the story.” Especially for higher levels of care, robust records and notes are critical to making sure that continuing care gets authorized. She said, “Payers reviewing notes must know what’s happening with a consumer and what is the goal is for helping that consumer on the road to recovery or keeping them in the community or getting them back to a functional baseline.” And Ms. Jones said that in addition to training, clinical professionals at MHA have their notes intensively reviewed for the first 90 days on the job and then they are “graduated” to less review, which saves supervisory time. But if anyone is “struggling,” they get back on intensive note review.

Show clinical professionals what’s in it for them, suggested Dr. Clayton. Tell them what will make their work easier and help them get it done in less time. Offer incentives to staff based on their rate of efficiency with their documentation. Tell them how they are doing compared to their peers, and recognize and celebrate improvements. Ms. Jones said they give out “report cards” to staff, showing how they are doing month to month in timeliness and quality of notes, and that has helped to improve performance.

As the field moves to more of a focus on value, the need for data and clinical documentation will only grow. The challenge for executives is how to get more value out of the process. How to improve the quality and decrease the cost of data collection—and ultimately how to leverage that data for competitive advantage. For more on effective clinical documentation and decisionmaking, check out these resources in The OPEN MINDS Circle Library:


This reprint appears with the permission of OPEN MINDS. For more information, visit their website at To contact the author, email