In recent years, the Saudi Ministry of health (MOH), the Saudi CHI and Saudi health holding company (HHC) have been steadfast in their mission: driving healthcare professionals (HCPs) to fully adopt Clinical Practice Guidelines (CPGs) and a value-based care approach. The goal is clear; optimize operations, control costs, and, above all, ensure high-quality patient outcomes.

But as any practicing physician knows, it’s not enough to merely follow clinical guidelines; doctors must also be able to PROVE its, especially when doctor documentation is under review for accreditation or payment.

Universal Compliance Across Specialties

Whether a family physician or a subspecialist, the adoption of evidence-based clinical decisions, tailored to the patient clinical setting and sensitive to care expenditures is now expected. Regulatory bodies want to see a demonstrable link between doctors’ clinical actions and national (or international) CPGs.

Proving Compliance: The Role of Clinical Documentation and Coding

How can doctors document compliance? Here’s what matters:

• Clear, structured clinical notes. Use standard formats like SOAP (Subjective, Objective, Assessment, Plan) to reflect how doctors’ decisions followed guidelines.
• Explicit mention of CPGs. Reference the specific guideline or protocol guiding diagnosis or treatment.
• Thorough justification. If doctor deviate from the guideline, carefully document clinical reasoning.
• Accurate Coding. Assign the right ICD-10-AM codes and procedural codes corresponding to the CPG-driven diagnoses and interventions.

This documentation protects doctors and patients and stands up to both internal and external audit. Reviewers do not just look for what was medically done, but why it was done as well, and if that why is anchored in best-practice guidelines.

The Impact on Hospital Accreditation

Doctors quality of clinical decisions, and how well it was documented, are core indicators in hospital accreditation processes. Bodies like CBAHI and CHI scrutinize alignment with clinical guidelines. Poor or incomplete documentation can jeopardize not just doctors personal compliance but hospitals’ standing and funding.

1. Compliance is Required — For Every Specialty, Every Setting

Whether in a primary care clinic, a tertiary hospital, or a specialized center, the expectation is the same: your clinical decisions should be evidence-based and aligned with published CPGs.

Example: A family medicine physician treating a patient with newly diagnosed hypertension should reference the Saudi Hypertension Management Guideline. Similarly, an endocrinologist managing a diabetic patient is expected to document their alignment with ADA or national diabetes recommendations — for instance, using metformin as first-line therapy unless contraindicated, and explicitly documenting any justified deviations.

2. Proving Compliance Through Clinical Documentation and Coding

What do reviewers and auditors look for? How can doctors demonstrate compliance?

Structured Documentation:

Use standardized templates such as SOAP (Subjective, Objective, Assessment, Plan) notes to make clinical reasoning transparent.

• Subjective: Document patient-reported symptoms and relevant history.
• Objective: Record physical exam findings and key investigations.
• Assessment: Explicitly state the diagnosis, referencing the relevant CPG (e.g., “Diagnosis: Asthma according to GINA 2024 criteria”).
• Plan: Tie management back to guidelines (“Initiated inhaled corticosteroid as per GINA stepwise approach. Patient education provided.”).

Explicit Reference to Guidelines:

Example: “Started statin therapy in a 55-year-old male with T2DM per Saudi MoH lipid guidelines. No contraindications present.”

When deviating, clearly explain: “Did not escalate to insulin due to patient refusal and concern for hypoglycemia. Will reinforce counseling and re-evaluate in one month.”

Accurate Clinical Coding:

Assign the most specific ICD-10-AM codes and procedure codes to capture adherence.

Example: For a severe non-responding asthmatic exacerbation in the ED, document not just “asthma,” but “J46: status asthmaticus.” For diabetes patients with complications, use addition codes (e.g. E11.21: Type 2 diabetes mellitus with diabetic nephropathy).

3. Why Auditors and Accrediting Agencies Care

Clinical documentation is not just for the medical record, it’s for patients, hospital as an institution, and regulatory bodies such as CBAHI and CHI.

Example: CBAHI or CHI surveyors may randomly select patient charts and verify whether initial treatment for community-acquired pneumonia follows the national protocol: Was a CURB-65 assessment performed? Were empiric antibiotics initiated as recommended?

Inadequate documentation can signal non-compliance, resulting in audit issues, delayed reimbursements, and negative impacts on the hospital’s accreditation status.

4. The Direct Link: Documentation, Coding, and Accreditation

The doctor ability to demonstrate high-quality, guideline-concordant decisions not only supports patient safety but also solidifies the institution’s readiness for audits and inspections.

Example: accreditors may review cancer diagnoses to check if staging, multidisciplinary discussions, and management plans are documented as per international cancer guidelines. Incomplete or ambiguous documentation can risk accreditation lapses.

How Glance Care Solutions Empowers Compliance

Glance Solutions helps doctors, clinical coders and RCM officers bridge the documentation gap and exceed compliance requirements through powerful features:

• SOAP Note Builder: Structure every encounter for clarity, surveillance, and auditing ease.
• Quick Coder: Instantly assign accurate clinical and procedural codes, supporting precise, guideline-informed documentation.
• Smart Note Taking: AI-driven prompts help you reference guidelines and document clinical reasoning thoroughly.
• Patient Engagement and Referrals: Collaborate efficiently with patients and with confidence, underpinned by guideline-based documentation.

In Summary: Adapting to CPGs and demonstrating value-based care is the new norm for all Saudi HCPs. Robust documentation, clear, precise, structured, and correctly coded isn’t just administrative: it’s the doctors best proof of quality, compliance, and professionalism. With the right digital tools, like Glance Solutions, doctors can focus more on patient care and less on paperwork, confident that care always meets the highest standards.

Are you ready for the next accreditation cycle? Try Glance Solutions and ensure your clinical documentation is your strongest ally.