The Role of CDIP in Providing Quality Health Care Services

Medical institutions have the ongoing challenge of ensuring organized and systematic daily operations as medical staff and personnel are required to adapt to modern methodologies and practices in clinical documentation. Medical records contain delicate information that is needed to be secured for future or immediate reference especially when it comes to the identification of an effective medical plan. Documents are supposed to serve as evidences to describe something that actually happened. In the field of health care, documents are expected to be patient centric as they are designed to describe all details related to the conditions of the patients. Clinical documents serve as forms of communications among medical personnel and through various clinical documentation improvement programs or CDIP, they are enhanced to provide reliable, accurate, and accessible information.

Management of clinical documentation involves the use of modern technology and IT solutions. Different types of media, software, and application can be used to provide both convenience and accuracy in the practices involved. Medical professionals are able to resolve different problems through effective documentation. A lot of existing medical concerns are easily identified and resolved because previous cases were properly documented. CDIP ensures that medical records are properly documented and they resulted from the regularly conducted audits. Since audits aim to identify rooms for improvements, vital aspects such as documentation are given much attention. Medical institutions are able to manage daily workflow through proper documentation. At the same time they are able to maintain good reputation by avoiding legal issues and non compliance. It is very important for clinical documents to be complete and legal according to agreed standards and regulations.

A medical institution is considered efficient if daily operations are smooth, organize and systematic. This can only be possible through effective documentation. CDIP ensures that your current system of documentation is up to date to support the medical demands of the modern society. It is therefore important to be up to date to the latest trends. This will involve new terminologies and applications that are based on products of Information Technology. But there is nothing to worry about because part of CDIP is the careful review of existing documentation practices and find the appropriate modern methods that fit. This way, medical personnel will not have problems adjusting and the proposed changes will not affect or slow down daily operations. CDIP will then be a part of the major improvements in a certain medical institution.

Health Care Services

There are many health services and a proper range of health care services needs to be provided under a proper healthcare system. The United States does not have the best health care services in the world but it can be said that it has the best emergency care system around the globe. The fact behind this is that America is having highest level of poverty and income inequality among all the rich and developed nations and it affects the reach of the people to the proper health services.

Health systems are designed to fulfill the needs of the health care of some targeted nation or population. Health care planning and its proper system implementation are much more necessary for any country or government. According to the World health report 2000 “Improving performance are good health, responsiveness to the expectations of the population, and fair financial contribution.” Duckett (2004) proposed a two dimensional approach to evaluation of health systems: “quality, efficiency and acceptability on one dimension and equity on another.”

To have a best health care facilities UNICEF advises that there must be three primary steps which can then systematically improve the health services and to complete a health system.

1. Standards
2. Assessment and Accreditation
3. Support Materials

Seven years ago World Health Organization made the first major effort to rank the health systems of 191 nations. The following parameters were taken in consideration for the best care services;

· Insurance Coverage
· Access
· Fairness
· Health Lives
· Quality
· Life and Death
· Patient Satisfaction
· Use of IT
· Top of the Line Care
· Walk in clinic

Health is a state of well being, physically, mentally, socially and psychologically. Health services are fundamental part of any community, therefore financial stability and proper coverage of medical through insurance or some other way is very much necessary for a human to live and stay normal. There is a proper process oriented structure is required, implemented by the government to provide the health services to each and every of their citizen. The health care industry is responsible to provide the proper health care services to the people with their arm namely health services providers. These health services are paid and could be paid by the patient, by insurance plan, or by the government. Charities and volunteers also play their role to provide the health services to those who are unable to afford. There could be various ways to provide health services to the patient, normally can be categorized into two main;

· Face to Face:

This is the most common way, where the provider, interacts with the patient physically and after having the checkup and understanding of the issues, diagnoses the problem or suggests some tests or medication.

· Non -Face To Face:

Telecommunication is the latest emerging facility, which is now in use to provide healthcare services as well. The practitioner can interact with the patient using, phone, email, text message, or video conferencing and then can provide further suggestions to him / her.

Health services are also provided at schools where the children could be taken care of. UNESCO has published a set of tools to provide the guidance to school healthcare services providers. Following are the basic parameters which must be catered;

· Food and nutrition
· Helminthes and hygiene
· Malaria
· Violence
· Drugs, tobacco and alcohol

In any health services providing system there could be the following three types of health services.

1. Primary Health Care Services:

Whenever someone needs a health care service in normal and routine life, who could be a family doctor, nurse, nurse practitioner, physiotherapist, pharmacist, etc. Primary health services often include prevention and treatment of common diseases and injuries.

2. Secondary Health CareServices:

Whenever someone needs a special care he/she is referred to a specialized care unit, like hospital, or nursing home to provide secondary level of health facilities.

3. Additional / Supplementary Health Care Services:

The services which are normally provided to the senior citizens, children or to whom which do not have their proper medical coverage or paying capabilities and the expanses are covered through government funds or through some volunteer or charity organization.