Clinical documentation improvement program is all about proper record keeping at par with the regulatory body’s rules and regulations. The nurses maintain the records and the physicians are very important not only for treatment but also the data thus collected may be referred to during a medical research. The documentation should be a medium of communication and the data thus collected should be accurate, concise and to the point. However, with the technological advancements and many heading to take up the professions as their career, the regulatory bodies are making their standards high and are focusing on providing quality care.

The clinical documentation improvement program involves collecting every possible details pertaining to the treatment, medications, medical reports, details of the communication with the physicians, emergency contact details, address and everything related to the patient. It should also include the name, age, DOB, sex and even the emergency contact details of the patient. Moreover, any entry made in the clinical documentation has to be signed with the date and time. In addition, any entry that has already being made in the documentation cannot be cancelled just like that. The use of any sort of correction ink or white ink is strictly prohibited and anybody seen to do it with be placed under strict disciplinary action.

There are certain specifications regarding the type of ink that is to be used in the process- permanent ink is to be used and the writings are to be done with a certain amount of pressure and of course be legible. These are very important and must be maintained, as the data collected in the process of the total on-going treatment may be referred to in the future for nay research purpose, even though the treatment has long been completed. The total process of clinical documentation improvement program should reflect a certain amount of professionalism from everyone- the doctors, the nurses and the paramedical or the allied medical officers.

The general rules of clinical documentation improvement program also include maintaining the records in a legible format and should allow the patient to be identified, justify the treatments provided, and keep all the related medical test records, diagnosis, medical histories, medication and all details. However, it is to be mentioned here that all these documents should be legally maintained as well. Technically, the daily records maintained in the documentation should also include- the objective findings, assessments, periodic assessments, treatments provided. The use of abbreviation is prohibited in the documentation, though only the very standard ones can be used.