The accuracy and completeness of clinical documentation are essential for joined-up, effective and safe delivery of care within an Acute Health Trust. Nuance has commissioned new research in this area that will provide Trusts with benchmarks to improve: •Information across patient care pathways •Doctor and nurse productivity •Trust-wide economics For more information into the background and outlook for the research visit www.nuance.co.uk/healthcare

1. New Research: The
Clinical Documentation
Challenge
The accuracy and completeness of clinical documentation is
essential for joined-up, effective and safe delivery of care within
a Health Trust. But what measurable impacts do accuracy and
completeness of clinical documentation along the care pathway
have on patient experience, doctors’ and nurses’ ability to care
and on the economics of the Trust?
Why is the research important?
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NHS England
Paperless
by 2018
NHS England
Five Year
Forward View
NHS England
Digital Health
Services by 2020
Infographic
Aligned with these goals, the accuracy and
completeness of clinical documentation are essential
ingredients for the achievement of integrated,
effective, efficient and safe delivery of care.
However, there’s currently no research relevant for the
UK healthcare environment that quantifies the impact
of clinical documentation on patient care, doctor
and nurse efficiency or Trust economics.
The research seeks to understand
the clinical process impacts
Methodology
Myriad components & systems
Some paper, some electronic
Patient Administration
(PAS)
Compliance, Assurance
& Legal Defence
Clinical Users:
Secondary Users:
Within clinics,
inpatient stay & between
multidisciplinary team members
Information for other clinicians
Including GP, Community
& allied services
Lab Results
Scans
Reports
Surgical
Notes
Treatment &
Therapy notes
Nursing notes
Assessments
Clinic Notes
Letters
Radiology
Integrated
Efficient
Safe
Using
ProvidingAdding
Coding & Reporting Predictive Analytics
& Research Data
1. Map and analyse the flow of clinical information across
typical patient care pathways
2. Identify areas most sensitive to clinical document
accuracy and completeness
Research Results
1. Discharge and transfer
2. Shift handovers
3. Emergency care records
4. Diagnostic reporting
5. Assessment
6. Outpatient and other clinic
notes
Risk Exposure
FinancialProcessImpact
1
6
3
4
5
2
–– To other providers: Discharge /
Transfer
–– To other areas: Assessments,
Reporting
–– To other shifts: Nursing Notes,
Clinical Handover Pharmacy
TTO
Transport
Discharge Information
Completion
EPM PAS
PAS
HR
EPM
Discharge Letter
normally electronic
with hardcopy for
patients
Example: Extract from Transfer Process of Care Pathway
EPM: Pharmacy e-Prescription
PAS: Patient Administration
HR: Health Record
This research has been commissioned by Nuance
and carried out by specialist research company,
Ignetica. To pre-order your copy of the full report,
due to release in May 2015 visit www.nuance.co.uk/
healthcare or follow us at www.twitter.com/
voice4health
Who will find the research useful?
Management, Clinical, Data and Governance Leaders in Health Trusts
seeking to maximise the return on their EPR and other clinical
documentation investments.
Will provide Trusts with business value performance indicators for accuracy
and completeness of clinical documentation to positively impact:
Patient care
pathways
Doctor/nurse
productivity
Trust-wide
economics
3. Prioritise areas for clinical documentation improvement
based on Impact versus Risk
4. Quantify impact on patient care, doctor nurse
efficiency and Trust economics