11 ways to make clinical documentation better with examples

Ashleigh Knowles
Ashleigh Knowles
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What is clinical documentation?

Clinical documentation refers to the recording of details pertaining to encounters with patients. Clinical documentation is an integral aspect of working as a healthcare professional, regardless of what specific field you work in. Because these documents have such a significant role to play in various processes, looking for ways to improve your note-taking is always a good idea. 

Not only are clinical notes required for insurance contexts, but they have been shown to elevate the patient quality of care and improve clinical outcomes. It is understandable that clinicians can find it difficult to keep up with the amount of note-taking that is required of them, whilst also ensuring their documentation is consistently accurate. One study suggested that around 70% of patient records contain false information, an alarming statistic considering how important documentation is. Ultimately, regardless of whether you are just starting your career or are a seasoned professional, clinical documentation improvement is always possible. 

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Importance of clinical documentation in any healthcare setting

Before you can effectively begin improving your methods of clinical documentation, it is critical to understand exactly why they are so important. Effective clinical notes will have various advantages for your healthcare practice, including:

Productivity: When operating a healthcare business, it is always in your best interest to look at ways to improve productivity. An unproductive practice will lead to clinicians spending a lot of their time on administrative tasks, which can reduce the number of patients that are being seen. Efficient clinical documentation will save a lot of time, as physicians don’t have to search for notes, and the actual writing process is significantly reduced.

Patient satisfaction: As the healthcare industry shifts to value-based care, it is important for practices to implement new systems aimed at achieving patient satisfaction. Effective clinical documentation can help with this, as patients can access their medical records and the process of delivering care is made more transparent. 

Progress: As I’m sure you know, one of the sole reasons that clinical documentation is required is because it tracks the progress of your clients. Effective clinical documentation will lead to more accurate progress monitoring, allowing businesses to improve clinical outcomes and continuity of care. 

What makes clinical documentation effective?

There are several approaches to ensure the effectiveness of your clinical record. While it’s true that anyone can document clinical notes, there are some elements that you should add to improve the efficacy and quality of your material. Failure to preserve accurate records can lead to serious complications later on, thus it's critical to prioritize patient care through good clinical notes. You can protect yourself from legal issues while remaining professional and truthful to what the patient is feeling. Both you and your clients can benefit from effective notes, which also contribute to more effective healthcare outcomes. 

Effective clinical notes will have accurate information that is consistent and true to the experience of the patient, and also reflects any updates or changes made. They will be recent, factual, and easy to understand. All entries are legible and signed, and only contain relevant details that pertain to the patient. Confusing jargon and abbreviations are avoided, and any healthcare practitioner, regardless of their practice, will be able to pick up where you left off. To summarize, good clinical notes will have:

  • Factual information
  • Up-to-date details
  • Legible entries
  • Signed entries
  • No jargon
  • No confusing phrases or abbreviations

What causes clinical documentation to have poor outcomes?

Sometimes clinical documents can miss the mark, so it’s important that you’re aware of what can contribute to these poor outcomes in order to avoid ineffective note-taking. While the answer can vary from person to person, essentially, anything that makes it difficult to record patient information may result in poor documentation for practitioners and healthcare professionals. In some ways, there’s a certain art to clinical documentation, and it may take some time to master. However, it’s not difficult, and with the right time dedicated to editing, you can ensure you’re up to scratch. 

Information containing incorrect details can easily lead to misdiagnosis and ineffective treatments, so make sure that you spend time double-checking details! You don’t want to lose patients, complicate health matters, or dampen your reputation. As a result, you should consider the following aspects, as clinical documents that contain these mistakes are more likely to result in poor outcomes for your healthcare clinic.

  • Inaccurate entries
  • Spelling errors
  • Missing details
  • Copied and pasted information
  • Failing to correct false data
  • Using service providers who struggle with understanding medical jargon

10 effective tips to make your clinical documentation better

CDI (clinical documentation improvement) programs are being implemented into hospitals and private practices at an increased rate, reflecting the growing challenges associated with receiving accurate reimbursement. We have collated some of the key strategies that often accompany these programs to help you ensure your clinical documentation is as effective as possible:

Data: In order to improve clinical documentation, you must first identify the specific aspects that require improvement. By observing the documentation through data analysis, you will be able to pick up on the inefficiencies. For example, you might find that some notes have discrepancies, missing information, or coding deficiencies. Data analysis will allow you to target these specific areas and ultimately improve your documentation.

Quality over quantity: It is important that your clinical documentation is thorough and accurate, but this doesn’t necessarily mean it has to be lengthy. Progress notes should never exceed two pages in length, and you should avoid vague language and lengthy sentences. 

Timely: There are two reasons why clinical documentation needs to be completed in a timely manner. Firstly, these notes need to be accurate, and the best way to ensure accuracy is by writing them whilst information is fresh in your mind. Secondly, all forms of clinical documentation are dated and signed, and it will work in your favor if you consistently write your documentation in a timely manner.

Software: As technology continuously develops, we are seeing an increase in the number of healthcare practices implementing these systems into their business. Software allows for effective practice management by providing clinicians with a secure storage location, and various tools that streamline the clinical documentation process.

Templates: Various documentation templates are available to physicians, and you shouldn’t be afraid to use these. Regardless of what specific format you prefer for your documentation, these templates will help you increase consistency and ensure you don’t leave out any important information. 

Central database: Regardless of whether you decide to implement an EMR into your practice, all of your clinical documentation should be stored in a central database. This means that clinicians won’t waste time searching for documents, and they are accessible 24/7.

Workflow: CDI programs are likely the best way to improve the clinical documentation of your practice. If you incorporate one of these programs into your clinical workflow, then physicians will be able to efficiently improve their documentation without it interrupting their regular schedule.

Keep up to date with guidelines: As the guidelines for medical billing and documentation frequently change, it can be difficult to stay up to date. However, ensuring you are aware of updated guidelines will allow you to reduce the number of reimbursement rejections and denials your practice receives, allowing you to get paid on time.

Educate: This might seem obvious, but it is critically important that your physicians are aware of the reasons why CDI programs are important. If they don’t understand the uses of clinical documentation, then it will be difficult for them to improve theirs.

Continuous progress and performance monitoring: Lastly, to ensure that any improvements made to clinical documentation methods are long-lasting, you should monitor progress and performance continuously. This will ensure physicians maintain accountability, whilst also giving them long-term support.

Clinical documentation app

How to document phone consultations

It’s quite common to take phone consultations in healthcare, and if you haven’t already, you may soon find yourself having to take notes whilst conversing with clients on the line. Especially within this COVID-19 climate! Phone consultations can be quick, easy, and more comfortable for all parties involved. Taking calls from home can help clients feel more at ease when it comes to healthcare, and they’re also significantly more convenient to slot in with busy schedules, with no physical distancing required. However, it seems to be that they’re quite often overlooked when it comes to clinical documentation. 

Naturally, taking phone calls isn’t the standard way of conducting healthcare appointments, and sometimes it can be difficult to remember all the points that were covered. After all, there are no physical cues to help you, and in cases where there is limited time, many significant talking points can be skimmed over. However, not to fret! Following these tips, you can ensure that you’re able to take note of all critical details in your phone consultations, whilst engaging with your patient and attending to their concerns. 

Note the actors involved - It’s important to write a note that clearly outlines who was involved in the conversation, and what their role was. 

Document with others - Make sure to document your conversation with relatives of the patients or other medical professionals involved in your patient care. 

Summarize! - Make sure to jot down all the main points covered and information. Use concise paraphrasing to ensure you don’t miss anything. 

Take note of phone numbers - Quite often, you may have to contact others, and in this case, make note of any relevant phone numbers - even if you think you have them on hand. 

Examples of excellent clinical documentation

Clinical documentation will look slightly different, depending on whether you are a nurse, general practitioner, psychologist, or therapist. Nevertheless, if you employ the above strategies in your work, you are guaranteed to increase the accuracy of your documentation. Implementing sophisticated healthcare software into your practice will undoubtedly provide you with the resources required to elevate your clinical documentation. These systems should have a unified workflow, note templates, and cloud-based storage capabilities to allow you to produce consistently excellent documents. 

Examples of clinical documentation include:

#1 SRIP

Situation (S): Focus of the session was aimed at introducing new coping skills to manage depression. Samantha appeared fatigued, as highlighted with minimal conversation and an apathetic attitude, stating “I don’t really care about my graduate tomorrow, I’d honestly rather just stay in bed”.

Intervention (I): Samantha was encouraged to walk for 30 minutes a day once a week, with journaling also encouraged to engage her emotions. Group therapy was also an option for her if desired. 

Response (R): Samantha achieved her goal of a 30-minute walk, and made 2 journal entries. She was reluctant to attend group therapy. 

Progress (P): Samantha will attend her therapy session next Wednesday, and the session will focus on her progress and coping methods. 

#2 SOAP

Subjective

Liam reports he has been compliant with his medication and meditation app whenever he has felt anxious. 

Objective

Liam appeared calm and relaxed when talking with me today. No fidgeting or anxious movements. 

Assessment

Liam could articulate his thoughts clearly and with a normal rate and volume. There were no side effects of the medication presented. 

Plan

Plan to meet again in person at 4 pm next Wednesday, 20th April. Liam will continue with his current medication, and the meditation program gave effectiveness. He has been given resources to contact if needing urgent help for whatever reason before our next session. 

#3 DAR

Data: "Consistent ache in the left arm," pain 7/10. Tramadol 15mg was given at 0900 which resulted in medium reduction of pain. 

Action: Educated the patient on medicine use, and alternatives to current prescriptions in the case of more urgent relief. These included Oxycodone 2mg and Tylenol 500mg in addition to breathing exercises. 

Response: With current medication, the pain has reduced to 3/10. The report was then passed onto the primary nurse, who recommended a swap to Oxycodone prn. 

#4 DAP

Data: John has been sleeping ‘6 hours per night’ and expresses concern about struggling to concentrate at work. His mood is somewhat down, stating that he has ‘not enjoyed reading as much.

Assessment: John seems to present mild depression symptoms and has no family history. 

Plan: John has been provided with coping techniques to encourage proactivity. He has started with a goal of turning off electronics by 7:00pm, and going for a 30-minute walk 5 times a week. A session is scheduled for next Friday, and if there is no progress, 20mg of sertaline may be considered. 

Conclusion

The importance of clinical documentation means that every healthcare practice should constantly be finding ways they can improve their notes. Although how you choose to construct your documentation is largely dependent on personal preferences and the field of healthcare you work in, we recommend implementing electronic software that can streamline this process. Carepatron offers a fully integrated, HIPAA-compliant platform that is guaranteed to improve your clinical documentation. It is mobile-friendly and comes with various note templates, medical billing features, and cloud-based storage capabilities. Your notes will be easier to write and easier to store, granting both patients and physicians 24/7 access, regardless of where they are in the world.

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