Clinical documentation is one of the most important aspects of working in healthcare. Regardless of what specific field of healthcare you work in, you will inevitably be exposed to some form of documentation and it is your responsibility to understand why it is created and what it is used for.
If you are currently working as or training to become a healthcare professional, you might find you have little time on your hands to complete further research and study. Luckily, that’s where we can help.
We’ve done the reading and evaluating for you, and now consider ourselves to be somewhat of an expert on clinical documentation. We’ve broken down all the important information into different sections, to make everything as digestible as possible. Basically, we’ll cover the following:
Whilst many training and education programs touch on the basics of documentation, usually, it is not until practitioners start doing the documenting themselves that their knowledge is truly consolidated. Unfortunately, failure to produce accurate clinical documentation can have negative consequences for both patients and physicians, a situation you want to avoid at all costs.
Basically, clinical documentation refers to the collection of records and documents pertaining to an individual’s healthcare. Amongst other things, this may include information regarding symptoms, diagnoses, medications, treatments, tests, and assessments. Collecting and storing all of these records allows practitioners to have greater insight into the health status of their patients, enabling more informed decisions and ultimately improved clinical outcomes.
In addition to the general importance of having updated patient records, there are a ton of different situations that require the use of clinical documentation.
Inter-provider communication: Imagine a patient that has regularly seen the same psychologist for the past couple of years. Now, one time the patient is desperate for an appointment but their psychologist is away for the upcoming few weeks. The patient decides to book an appointment with a different psychologist at the same clinic, who is then granted access to the patient’s clinical documentation. Accurate documentation ensures that the new psychologist is informed about the patient’s current treatment plan, diagnoses, and medications and is thus able to treat them as effectively as possible.
Clinical documentation is also shared between healthcare providers working at different facilities. It is often the case that a patient’s treatment within the healthcare system spans across various different departments and facilities. As such, it is critical that each of the patient’s healthcare providers have a method of communicating effectively with each other, a process that can be facilitated by good clinical documentation.
Protection: As well as protecting the patient and ensuring they are receiving the best quality of care possible, clinical documentation also serves to protect practitioners. Documenting each encounter with a patient not only ensures that practitioners are held accountable, but also creates evidence for potential malpractice suits. Medical records are legal documents that can provide evidence for the service delivered.
The various uses of clinical documentation can be overwhelming, and it may help to think about it as having three main purposes:
There is a common saying in the healthcare field that goes: “If it isn’t documented, it didn’t happen”. If you are a practicing healthcare professional who sees and treats patients, then it is your responsibility to maintain clinical documentation. Every single encounter with a patient should be documented accurately and efficiently, regardless of whether it was a phone call or a 2-hour long appointment.
A common misconception regarding clinical documentation is that it is only required in certain fields of healthcare. This is not true. Clinical documentation is a general requirement of almost every healthcare profession, including
However, whilst these practitioners are generally responsible for the creation of their patient’s clinical documents, different practices will have their own methods of monitoring this process. Some clinics may choose to employ clinical documentation specialists, who spend their time reading, verifying, and authenticating documents. These specialists may serve as a go-between for the healthcare practice and the insurance company, making sure that claims are accurate and reimbursement is received.
There are plenty of reasons why your practice should be constantly focusing on creating high-quality clinical documentation:
Improving clinical outcomes: As we have already mentioned, documentation plays a key role in improving clinical outcomes for patients - and this should always be the number one priority of delivering any type of healthcare service. Healthcare providers often consult clinical documents, so ensuring they are accurate and effective will facilitate better decision-making.
Legal situations: Clinical notes can be used as legal documents in certain situations. Although practitioners should be doing everything they can to avoid being involved in a malpractice or clinical negligence suit, it is important that they have the relevant documentation in place just in case.
Insurance: The process of submitting medical claims and receiving reimbursement is becoming increasingly complex. One of the best ways to avoid claim denials and rejections is by having reliably accurate clinical documentation. False or missing information can delay the reimbursement process, impacting the entire healthcare practice.
Patient satisfaction: The healthcare industry is moving to a system of consumer-based care, in which patient needs and wants are being prioritized at a greater rate. One of the fundamental components of consumer-based care is a focus on patient satisfaction. In the modern healthcare age, an increased number of patients want their treatment process to be as transparent as possible. As a practitioner, you can choose to share your clinical notes with your patients to elevate transparency and keep them informed of your professional decisions throughout the treatment process. Good documentation can elevate transparency, which in turn contributes to greater patient satisfaction.
Tracking progress: One of the most fundamental purposes of writing clinical documentation is to track the progress of patients. If a patient has had a leg injury and is seeing a physical therapist over an extended period of time, it is important to document their improvement. Looking at the therapist’s documentation should be enough to indicate how much progress the patient has made, and what the next steps of the treatment plan are. This becomes even more important in situations where a patient’s usual therapist can’t see them, and they are treated by a different practitioner.
Productivity: As I’m sure you well know, the best healthcare practices are the most productive ones. Sometimes it can feel as though there aren’t enough hours in the day to attend appointments, follow up with patients, complete documentation, and finish administrative tasks, so figuring out ways to streamline as many processes as possible is in your best interest. Learning how to continuously and reliably create effective clinical documentation will end up saving you and your clinic countless hours of valuable time.
Knowing exactly why writing good clinical documentation is important is the first step to becoming a skilled documenter. Step two is recognizing what good documentation looks like, and figuring out how you can optimize your own record-keeping.
Every healthcare practitioner has their own personal preferences related to how they choose to write their documentation. Nevertheless, there are certain key elements that are necessary in order for the documentation to be effective. These include:
Despite the fact that writing clinical documentation is an inherent aspect of every healthcare practitioner’s work, an alarming amount of record-keeping contains mistakes.
A recent report indicated that up to 70% of patient records contain false or missing information. Whilst it can feel frustrating having to spend so much time on documentation when you would prefer to see and treat patients, record-keeping has an immense role to play in the delivery of healthcare services.
Fortunately, learning how to write high-quality clinical documentation isn’t overly complicated. In the table below, we have identified various do’s and don’ts that should help direct you to become the best documenter possible:
As a healthcare practitioner, there are various resources that have been developed to help you write your clinical documentation.
One of the most effective of these is progress note templates. After each session with a client, practitioners are required to document what happened during the appointment by writing a progress note. There are various different progress note templates that have been developed to assist practitioners, but the most commonly used is known as SOAP. The basic structure of a SOAP note looks like:
Subjective (S) - This section focuses on the client's feelings and experience of their symptoms and often uses quotes as primary evidence for support.
Objective (O) - Includes relevant factual data to support the symptoms reported by the client. Examples of evidence may include medical records, x-rays, examinations, test results, laboratory data, and vital signs.
Assessment (A) - This section is a combination of subjective and objective observations, including the current diagnosis, improvements noted, and specific tasks that may benefit the client.
Plan (P) - Includes the direct course of action for the client, focusing on any adjustments required for their treatment plan. This section should introduce specific goals for the client to achieve, as well as upcoming appointments and/or referrals.
Bob has been making improvements in regards to his anxiety, stating, "I feel anxious throughout the day, but it's nowhere near as frequent as it used to be." He says, "I don't feel restless that often, and if I do, I usually just go for my run routine as you suggested, and I feel much better." He says his appetite is "slowly coming back."
Bob still has anxiety symptoms, including a loss of appetite and racing thoughts with restlessness. However, these have reduced in severity and Bob demonstrates some regulating behaviors, which is an improvement.
Bob still has anxiety. However, he is making improvements, with symptoms decreasing in nature. They are becoming less prominent in his day-to-day life, but treatment is still needed to solidify his progress.
As usual, Bob will see me next week, and we have worked further on his regulating techniques to combat ruminating. He will continue to implement what we have worked through, and if symptoms stagnate within the next two weeks, we will reassess his treatment.
In recent years, the development of technology has led to the introduction of Electronic Health Records (EHRs) into the majority of healthcare practices.
These systems provide a centralized database that can store patient records and various forms of documentation, improving accessibility and organization. Whilst the transition to implementing electronic storage methods into healthcare practices has been relatively seamless, it has resulted in a divide between how practitioners choose to complete their documentation: electronic or handwritten.
Practitioners who are used to their own system of handwriting clinical notes may prefer to stick to what they know best. And despite the various advantages associated with electronic methods, sometimes sticking to what you are comfortable with leads to the best results.
In saying that, there are a few disadvantages that come with handwritten documentation. Firstly, your documents need to be organized and accessible. This means neat handwriting with limited to no spelling or grammar mistakes. It also means you need to have an organized and efficient storage method that allows for quick access and retrieval. The other issue with handwriting notes is that they are at a much higher risk of being stolen or lost. If you are in the habit of only writing one copy, then a lost document poses significant risks to both you and your patient.
Younger practitioners or those wanting to embrace developing telehealth resources have begun to write their notes electronically and once again, this method comes with its own set of pros and cons.
The good thing about creating your documents electronically is that it guarantees both organization and accessibility. Using an EHR system means that your notes are automatically uploaded and stored onto a centralized database, where they can be accessed by authorized users. Additionally, cloud-based technology saves your documents in real-time, decreasing the risk of losing any notes.
Writing electronic clinical notes can also save you significant amounts of time. Many healthcare systems are integrated with note templates and other resources that can help you streamline your documentation process whilst simultaneously improving your consistency and accuracy.
In terms of disadvantages, one of the biggest risks associated with electronic documentation is related to cyber security. Despite the use of various sophisticated protection features, storing data online inevitably poses the risk of cyberattacks. When selecting a service provider for your practice, it is critical that you research their security measures. You are responsible for your clinical documentation, and it is essential that you take patient privacy seriously.
So what should you use?
Whilst how you choose to write your documentation is entirely up to you, research is pointing towards electronic methods as being the preferable option. They improve organization, accessibility and have wider time-related advantages for healthcare practices. Choosing the right software is critical for your success, but luckily there are many perfectly suitable options available.
When making the move to healthcare software, it is important that you develop some understanding of how these systems work.
Most healthcare platforms employ cloud-based technology, which refers to the use of information, applications, and resources over the internet, instead of on a hard drive. This means that your clinical documentation is stored on a remote server, where it can be accessed by authorized users from any device.
Cloud-based systems update in real-time, meaning that any changes to clinical documents or patient records are altered instantly. This ensures that providers are kept informed and aware of the current health status of their patients. Additionally, the maintenance and updates of cloud-based systems are managed externally, ensuring that your practice is constantly using the most recent technology without having to worry about internal maintenance.
Most healthcare platforms come integrated with various note templates for you to choose from. After you write your clinical documentation, it is encrypted and stored on a centralized database, where it can be accessed 24/7 by authorized users. Cloud-based technology is a highly sophisticated yet easy-to-use method of creating and storing all forms of clinical documentation.
One of the most difficult aspects of implementing new documentation software into your practice is deciding which one will work best for your business. Fortunately, as healthcare technology is continuously advancing, we are seeing a rise in the number of platforms developing sophisticated documentation systems. The features offered by each of these providers tend to be fairly similar, but to help you in your search and to develop your understanding of how this type of software works, we have compiled a list of some of the most popular systems.
Carepatron: Carepatron offers a fully integrated HIPAA-compliant clinical documentation platform. Practitioners can complete their documentation from any device, where it is uploaded and stored in real-time, using cloud-based technology. The clinical documentation process is assisted by various features, including note templates and voice-to-text dictation. The platform is integrated with a sophisticated EHR, medical billing and coding features, appointment scheduling, and a patient portal.
Therapy Notes: Therapy Notes is a cloud-based platform that specializes in mental and behavioral health. The system offers various customizable templates that have been specifically designed for practitioners working in certain fields, including psychologists, psychiatrists, mental health therapists, and counselors. The software includes an EHR and is also integrated with billing features, appointment scheduling, and a patient portal.
Simple Practice: Simple Practice offers a HIPAA-compliant platform designed to streamline the administrative tasks of a healthcare practice, including clinical documentation. Practitioners have access to a note template library, and documentation is securely stored using cloud-based technology. Simple Practice also offers features targeting appointment scheduling, billing, coding, and remote healthcare.
NextGen Healthcare: Also using cloud-based technology, NextGen Healthcare has been designed to help private practices optimize their efficiency. Clinical documentation can be completed from any device at any time, with an additional speech-to-text dictation feature. NextGen Healthcare is also integrated with a patient portal, online appointment scheduling, and telehealth features.
Now you know what clinical documentation is, why it is important and how to produce high-quality notes, you might be thinking we’ve covered all there is to know.
However, that’s not quite the case.
Because healthcare practitioners deal with such confidential information, there are certain guidelines that must be complied with after creating documentation. This is known as medical compliance. We’re not going to dive too deeply into the intricacies of how compliance works for healthcare practices, but it is important that you know how certain rules and regulations impact the creation and storage of your notes.
The most important thing for you to be aware of is HIPAA compliance. HIPAA (or the Health Insurance Portability and Accountability Act) is primarily concerned with patient privacy. The act outlines various guidelines that healthcare practices must adhere to to ensure the safety of patient data. We won’t go into too much detail regarding what each of these entails, but the five main guidelines of HIPAA are privacy, security, transaction, identifiers, and enforcement. Basically, a breach of HIPAA will result in negative consequences for the practitioner at fault and the practice they work for. This could mean a substantial fine, a suspension, or a loss of license.
Whilst you may consider yourself an expert on HIPAA and other compliance guidelines, you need to remember that any third-party service you use that handles your data also needs to be compliant. When researching remote service providers or healthcare systems, it is critical that they implement security protocols.
For example, Carepatron’s integrated healthcare platform meets or exceeds the following standards:
As part of their compliance guidelines, they employ the following protocols:
Bank-level encryption - Patient data is protected with multiple layers of AES-256 encryption. This ensures that all sensitive information is protected during the electronic transmission and storage process. AES-256 encryption is the same type of protection used by financial institutions and banks, ensuring that patient data is kept safe and secure at all times.
24/7 monitoring - AWS servers are controlled at the perimeter, as well as at entry points by personnel. Systems are monitored by professional staff through video surveillance, intrusion detection systems, as well as other electronic methods, all to ensure that there is also a physical layer of protection for your data. Having this additional layer increases the difficulty of information being leaked or hacked, and prevents sensitive patient data from being compromised.
Cloud accreditations and certifications - Carepatron is partnered with Amazon web services (AWS) to achieve three levels of certifications. These include PCI DSS Level 1 (Payment Card Industry Data Security Standard), FIPS 140-2 (United States Federal Information Processing Standard ),and ISO 27001 (Information Security Management System). This means that all online payments are highly secure, and all systems work in a coalition with information processing standards.
In addition to complying with HIPAA guidelines and other regulations dictated by local, state, and federal laws, it is important that your practice implements internal protocols. Clinical documentation often contains sensitive information (including a patient’s name, date of birth, medical history, diagnoses, and past treatments), so keeping this data safe is of the utmost importance.
We have compiled a list of basic, necessary tips that you should implement into your practice to elevate the protection and security of your data.
Clinical documentation is at the heart of almost every field of healthcare. As various processes, including medical billing and insurance, are becoming increasingly complicated, we are seeing a growing need for improving clinical documentation.
As such, an increased number of healthcare practices have begun implementing regular clinical documentation improvement programs. CDI programs are primarily focused on improving general documentation, coding, and reimbursement methods. Generally, CDI will analyze a practice’s current documentation procedures and identify areas requiring improvement. CDI focuses on the translation of a patient’s current medical condition into coded data. This process is known as medical coding, and whilst we won’t go into too much detail about how coding works, it is important to understand how it relates to documentation.
After clinical documentation has been written, it is turned into codes that are used for billing and reimbursement. In order for a practice to receive payment, these codes need to accurately reflect the patient’s condition and the services they received. Currently, the healthcare industry is showing an unfortunate trend of steadily increasing claim rejections due to inaccurate codes. CDI programs help to guarantee that the coding process occurs accurately and efficiently, ensuring that practices receive reimbursement for their services.
In addition to improved reimbursement, CDI programs have been shown to lead to greater patient care and data quality, culminating in a better healthcare experience for both patients and providers.
The healthcare industry is a highly fluid system that is constantly adapting to the patient and provider needs. One of the biggest changes that we are currently seeing in the industry is a shift to a model of consumer-based care. Amongst other things, consumer-based care places a significant amount of value on patient satisfaction, and one of the biggest influences on satisfaction is transparency.
Achieving transparency during a treatment process can cause a lot of stress for healthcare providers, especially if their patient is receiving care from multiple departments and facilities. Nevertheless, improving communication and establishing a safe and comfortable environment for patients should always be a primary focus for healthcare practitioners.
So how exactly can you achieve good transparency? The answer, as I’m sure you have already guessed, lies with clinical documentation.
Currently, there are a few barriers evident within the majority of clinical documents that are preventing patient engagement. Patients often struggle to properly access their records, despite the vast majority of practices using EHR systems. Further, clinical documentation isn’t designed to be read by patients, and is often filled with medical jargon and unfamiliar abbreviations. Lastly, there is also the issue of providers not wanting their patients to have access to clinical notes, fearing that they will be angered or upset by their contents.
However, if the goal of the healthcare industry is to establish a positive and trusting relationship between providers and patients, we need to find a solution to each of these issues. The complete breakdown of these barriers will likely take time, however, there are various strategies you can employ to elevate transparency and increase patient engagement with clinical documentation:
Reduce the jargon: We understand that using medical jargon speeds up the process of writing documentation, but it is important to recognize it is a barrier to patient engagement. Using universally understood language isn’t an overly difficult task for providers, and it is an easy way to improve effective practitioner-patient communication.
Objectivity: Clinical notes often include professional opinions regarding the health status of a patient. Whilst these are a necessary element of producing documents, it is important that you remain as objective as possible. A good way to look at it is by focusing on describing the patient’s behavior rather than making a judgment. Any statement you make should be backed up by some sort of evidence and you should refrain from using words that have negative connotations.
Patient portal: Patient portals refer to a personalized platform that contains a patient’s appointment details, payment information, and certain forms of clinical documentation. Patients are able to log onto their portals and access these resources, allowing them to stay up to date and informed about their health status and treatment plan. Patients can also utilize the direct communication channel it provides with their physicians, allowing them to raise questions or clarify aspects of their records/treatment that they don’t understand.
With the increasing focus on making the healthcare process as transparent as possible, it has become more important than ever to improve both the quality and accessibility of clinical documentation. It can be easy to forget that patients are often going through some of the most difficult and vulnerable times of their lives. Focusing on effective communication will help them to feel confident and comfortable with your services, improving quality of care whilst also enabling better clinical outcomes.
So now you know most of the important information regarding clinical documentation, what are the next steps that you can take?
The most important thing for you to remember is that your documentation can always be improved. As a healthcare professional, it is your responsibility to stay on top of your record-keeping and ensure all of your documents contain relevant information. If you run your own practice, you should be implementing various protocols and programs designed to elevate the documentation produced by your employees.
Although the actual process of writing documentation is highly dependent on the individual preferences of each practitioner, research continues to highlight the advantages of utilizing an electronic documentation system. With sophisticated software, your practice will be able to streamline the clinical documentation process whilst still focusing on creating accurate, consistent, and concise notes.
Ultimately, the most important thing you need to understand is the role that clinical documentation plays in the healthcare field. When you break it down, you can see that documentation has a type of trickle-down effect. When the documentation is good, then patient outcomes are better, communication is improved and reimbursement is faster. Consistently producing high-quality clinical documentation is one of the most effective ways that you can contribute to a better healthcare system with improved clinical outcomes and patient-provider communication.
If you are interested in furthering your knowledge of clinical documentation and how it interacts with various processes in the healthcare industry, feel free to read the below articles: