Welcome to the Foundation for Physician Documentation Integrity. This website will serve as an open forum for promoting quality clinical documentation through shared postings and engagement with physicians and other clinicians.
Physicians’ growing dissatisfaction with EMR documentation has been well documented1. Key frustrations include workflow that complicates rather than simplifies, difficulty in both entering and locating important information, and canned text that degrades rather than enhances the content of the medical record—all evidence that the role of the highest value member of the care team is being systematically devalued.
Our focus here is to present the compelling case that if physicians are allowed to create a quality narrative of the patient encounter, one that includes their clinical judgment and thought processes, then everything else should take care of itself; regulatory and payment issues will have been fully addressed in a manner that best serves the patient and the outcome of their care with a record that contains critical elements of the patient’s story and is both complete and accurate. Additional benefits of improved clinical documentation include the restoration of pre-EMR patient volumes, improved patient satisfaction, and reduced liability and audit risks.
Physicians’ rejection of today’s EMR’s documentation processes should not be interpreted as a rejection of technology2. Standard vendor responses of “you’re doing it wrong,” or you need “retraining” or “new templates” or “Dragon” have worn thin. Physicians embrace technology that works—technology that makes information easy to capture and easy to find rather than asking physicians to become data entry clerks and then creating or cloning large volumes of questionable text; technology that serves as a supportive adjunct to the physician, not a disruptive or ineffective tool that impedes clinical processes and the art of the practice of medicine.
This site will support thought-provoking white papers and case studies with real-world meaning for practicing clinicians. We will share best practice documentation standards and techniques to demonstrate quality documentation. This means coders, compliance officers and Clinical Documentation Improvement specialists can look to the record rather than the physician for information and enlightenment.
Our objective is to support clinical documentation that effectively captures the physician’s judgment and problem solving skills in a succinct and coherent fashion, facilitating better communication of care with colleagues and allowing more time for quality patient interaction—hopefully recapturing the joy of a quality practice of medicine along the way.