A Policy Brief for Improving Clinical Documentation: A Step Toward Hospital Cost Management

Background. Clinical documentation improvement is a process designed to accurately represent the severity of illness and patient care needs by thoroughly documenting diagnoses, comorbidities, complications, and services provided, thereby supporting the coding system. By ensuring precise cost calculations, the coding system helps prevent insurance deductions caused by incomplete hospital documentation. This policy brief aims to propose solutions that establish a framework for enhancing clinical documentation to reduce insurance denials. Methods. This policy brief is based on evidence from a mixed-methods study and a literature review conducted across the Scopus, PubMed, ISI, SID and Magiran databases. Additionally, interviews were conducted to gather internal evidence. Subsequently, policy options were evaluated through a focus group discussion with seven experts—two instructors from Health Information Management, two from Medical Informatics, and three from the Health Information Management department. These options were then ranked based on their benefits, disadvantages, and feasibility. Results. Policy alternatives include unifying clinical documentation guidelines, training clinical specialists, conducting periodic assessments of documentation with feedback, establishing incentives, preparing for the implementation of the DRG system, and utilizing artificial intelligence–based technology tools. Conclusion. Given the importance of accurate clinical documentation in reducing insurance denials, it is recommended that physicians receive appropriate training after the necessary infrastructure has been established and clinical documentation guidelines have been standardized. Medical record documentation should be evaluated at predetermined intervals, with feedback and designated incentives provided.