Understanding the Problems in Documenting Clinical Documentations: A Conceptual Analysis

Clinical documentations are at the core of every patient encounter.In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, and legible to accurately reflect the patient's disease burden and scope of services provided.However, getting complete documentation is difficult due to various factors.Thus, this conceptual paper explores the problems that healthcare facing regarding clinical documentations and initial insight regarding improvement of the clinical documentations.A total of 17 articles and journals were reviewed.The articles discuss about the problems, factors, theories, outcomes, and the limitation facing regarding clinical documentation.These articles reveal the effects of incomplete and inaccuracy of clinical documentations, benefits of Clinical Documentation Improvement (CDI) Programme, low cost improving documentation and compliance rate of clinical documentation.The impact from the clinical documentation is the hospital reimbursement.In Malaysia, the bundle payment model is used for hospital reimbursement and getting the actual budgeting.The findings emphasize the impact of inaccurate clinical documentation and the success of CDI program.However, in the future, researchers should evaluate the impact of documentation on patient care and the burden of completing documentation by the healthcare professional.