The "patient care team" implies the inclusion of individuals who provide direct care to patients. Professionals such as the following are most often recognized as members:
Physicians Nurses
Dentists Physician Assistants (PAs)
Nurse Practitioners (NAs) Pharmacists
Nutritionists Therapists and Rehab Specialists
Social Workers Case Mangers and Discharge Planners
Clinical Technologists and Technicians
Mental Health Workers
Chaplains or pastoral counselors
The patient care team works as a multidisciplinary interactive group, providing direct care and treatment to the patient. The team also will communicate and advise the patient family.
When we then look at the full “healthcare team membership,” we often find that it also includes the above, with the following additional staff and groups as well:
- Admitting/Patient Access
- Scheduling and Call Center
- Patient Financial Services and Billing
- Health Information Management and Coding
- Information Technology and Systems
- Administrative
- Collections and Finance
- Research
As we all know, we can’t discuss clinical coding without mentioning documentation. With clinical documentation, coding can reflect the severity of illness and risk of mortality of each patient. Documentation must be complete, timely, and accurate for each and every encounter. In today’s healthcare environment, clinical coding is gaining greater importance as we gauge the quality of healthcare using data, both for individual healthcare and the quality of a healthcare group as a whole.
One area that healthcare can do a better job with is the sharing of information and data, particularly as it pertains to clinical coding and the patient care team. We can and should be discussing what the coded data is telling us and what it is reflecting. Without greater collaboration and understanding of the clinical coding, our healthcare can’t and won’t be able to help us know how to improve patient care.
The time is now to work more closely with the patient care team and the overall healthcare team. We cannot and should not be working in silos.
With clinical coding being the reflective source of data to judge our patient care quality, we all should take the time and effort to develop lines of communication, align together, and build strategies that drive us to the highest quality in healthcare.