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The twelve Cs of clinical documentation
1Quality Management and Support Services, Parkside Care Corporation, Chardon, Ohio 44024, USA. Licapone1@aol.com
Home Healthcare Nurse
|November 24, 1999
Summary
Clinical documentation is essential, especially during challenging healthcare transitions like managed care. This article introduces the "12 Cs of Clinical Documentation" to improve efficiency and effectiveness for all staff.
Area of Science:
- Healthcare Administration
- Clinical Documentation Improvement
Background:
- Healthcare systems face ongoing challenges, including transitions in patient care (IPS) and standardized assessment (OASIS).
- The evolving landscape of managed care necessitates efficient and effective clinical documentation practices.
Purpose of the Study:
- To present a foundational framework for effective clinical documentation.
- To provide practical guidance for healthcare professionals to improve documentation quality and speed.
Main Methods:
- The article outlines the "12 Cs of Clinical Documentation" as a core set of principles.
- This framework is designed for easy adoption by both new and experienced healthcare staff.
Main Results:
- The "12 Cs" offer a reliable method to enhance clinical documentation.
- Implementing these principles can lead to more effective and time-efficient documentation.
Conclusions:
- Returning to fundamental documentation principles is crucial during periods of healthcare system change.
- The "12 Cs of Clinical Documentation" serve as a valuable tool for optimizing healthcare documentation processes.