Introduction to clinical notes - what are they?
When people think of the healthcare industry, their minds usually turn straight to the delivery of care to patients. And whilst this is definitely an essential aspect of healthcare, many other processes occur behind the scenes that are just as important – like clinical notes.
Healthcare practitioners are legally required to document their encounters with patients. There is a common saying that goes, “If it isn’t recorded, then it didn’t happen”. Every interaction, conversation, and consultation between practitioner and patient should have a paper trail, to protect both parties.
Understanding the role of clinical notes and how to create consistently effective documentation can be difficult, but that’s why we’re here to help. We’ve done some research and created a thorough guide that covers all the basics; what clinical notes are, why they’re important, how to write them, and what software (if any) you should use. If any of these topics interest you, we recommend you read on – you never know what you might learn!
So to begin – what exactly are clinical notes?
Basically, clinical notes are a required form of documentation that describes an encounter with a patient. There are many different types of clinical notes, including progress notes, psychotherapy notes, evaluations, treatment plans, and discharge papers.
The content within clinical notes will vary depending on a variety of different factors, including what field of healthcare you work in, the services you offer, and the needs of your patient. In saying that, there are definitely universally important aspects that are related to clinical notes, and these are what we will get into in this guide.
Regardless of what type of healthcare you work in, or whether you are a student or a seasoned professional, there is always room for improvement when it comes to writing clinical notes. In this guide, we’ll cover all of the essential information related to writing these notes, so that once you’ve finished reading you will be well on your way to becoming an expert!
Who writes clinical notes?
You might be wondering whether you are required to write clinical notes, and the short answer to this is: if you are a healthcare practitioner, then yes you need to keep clinical documentation. One of the biggest misconceptions about writing clinical notes is the belief that they are only necessary for specific fields, or in specific situations. On the contrary, clinical notes are written by a wide range of professionals from different fields, including:
- General practitioners
- Mental health therapy
- Occupational therapy
- Physical therapy
- Aged care
As you can see, clinical notes apply to pretty much every area of healthcare. If you see, treat or consult with patients, then you are required to document these situations.
Why are clinical notes important?
We believe that for practitioners to improve their clinical documentation, it is initially important to understand why improvement is necessary. So before we dive deeper into what exactly you should include within your clinical notes, we’re going to take a look at what role they play in the healthcare field, and why exactly they are so important.
To begin with, clinical notes are written largely to improve the quality of care of patients. During a patient’s experience within the healthcare system, there is a high likelihood that they will be treated by providers across a range of departments and facilities. As such, all primary caregivers must have access to relevant documentation so that they are fully informed and able to make the right treatment decisions. Clinical notes play a massive role in this process, as providers can refer to the documentation to ensure they have all the relevant, up-to-date information. Producing good clinical notes increases the likelihood of more effective care and better treatment outcomes, which highlights their merit and worth within the healthcare realm.
Different rules and regulations dictate how healthcare professionals are required to document their patient encounters and most often, clinical notes are a legal requirement. In the case of a malpractice suit, they can be used to determine whether the practitioner’s clinical decisions were ethical and reasonable. So not only can they be used to protect the practitioner, but they also improve the transparency of the treatment process, and thus, protect the patient.
The final reason why clinical notes are so important is related to the financial reimbursement of the healthcare practice. As I’m sure you know, the medical billing process is extremely complicated, and can also be time-consuming. Currently, the healthcare industry is experiencing the highest ever rates of claim rejections and denials, meaning that businesses are having to wait a very long time before they get paid. To counter this, practitioners must be producing accurate clinical notes. Often, these records are used by insurance companies to confirm the procedures that are documented on medical claims. If all of the information is correct, then the process of receiving reimbursement is significantly simplified.
Clinical notes have a role to play in a wide range of different healthcare processes. Putting time and effort into creating the most effective records possible will not only benefit your patients but will also give you a form of protection and ensure you get paid promptly.
Often, the administrative side of working as a healthcare professional is overlooked by the clinical side, but this is a mistake that can have serious consequences. As you now know, perfecting clinical notes will prove advantageous to both practitioners and patients and is a pursuit well worth investing time into.
What has to be documented?
In our introduction, we very briefly mentioned that clinical notes are required after every interaction with a patient - but what exactly does that mean?
Pretty much every time a practitioner communicates with a patient, they should be documenting the encounter. If you are in doubt about whether or not to write a note, it is always best to err on the side of caution. Interactions with patients can occur in a range of different situations, and we’ve compiled a list of some of the most common encounters that require documentation:
Appointment: Perhaps the most obvious, any appointment between a practitioner and patient should be documented. Appointments are typically documented using a note template (which we will provide examples for in a short while). Appointment notes should document the issue or concern raised by the patient and the practitioner’s treatment response. Although appointments are probably the most straightforward patient encounter to document, they can also be the most arduous and some practitioners procrastinate writing them. Whilst this is understandable, particularly for busy practitioners, clinical notes must be written as soon as possible after the appointment to ensure that the relevant information is still fresh in their minds.
Phone conversation: Keeping a record of phone conversations is an often overlooked aspect of documentation. After a phone call, practitioners should note down the concern or issue that was raised, or the main points of the conversation. Further, phone conversations with anyone involved in the care of a patient should be documented, including the patient themselves, a loved one, a different caregiver, or other medical professionals.
Group consultation: When a patient is receiving more complex care, or if your patient is a child, there is a high likelihood you will have group/family meetings to discuss treatment. These meetings must be properly documented, including who is present (patients, family members, social workers) and the main topics that were raised. When documenting a conversation, it is good practice to use quotation marks to indicate who said what.
Procedure: Unsurprisingly, every medical procedure requires documentation. The notes for a procedure should begin with when the patient gave their consent, and include details regarding the specific process and whether any complications or issues arose.
Mistakes: Finally, although practitioners should always be trying their hardest to avoid them, making mistakes is inevitable. Instead of brushing over them or trying to pretend as if nothing happened, you must record what the mistake was, when it happened, and what you did to rectify it. Transparency is becoming increasingly important in the healthcare industry, and documenting mistakes or errors in judgment is an effective way of improving trust between patients and practitioners.
As you can see, clinical notes are required for a very wide range of situations. If you are unsure whether or not you should be documenting an interaction with a patient, it is a good idea to err on the side of caution and write it anyway. Remember: if it isn’t documented, then it didn’t happen!
What should clinical notes include?
Now we’ve covered the basics: what clinical notes are, who writes them and why they’re important, it’s time to turn to their contents. We stated earlier that clinical documentation is required within every field of healthcare, yet the specific information that is included within records will differ depending on a variety of factors. Whilst this is definitely true, there are still certain pieces of information that should be included regardless of what field of healthcare you specialize in.
The basics of clinical notes:
- Date, time, and signature: Every clinical note needs to include the date and time of the interaction and the signature of the practitioner. Whilst this seems obvious, you would be surprised at how many practitioners forget to include these details.
- Names: In addition to the practitioner’s name and relationship to the patient, the clinical note should also include the name of the patient and anyone else present during the encounter (e.g. if it was a family meeting).
- The topic of the encounter: This is the aspect of a clinical note that will vary the most, but it could include symptoms, diagnosis, allergies, medications, and test results. Note that if a diagnosis is included, then it is important to state the relevant ICD-10 codes, for billing purposes.
- Intervention: This is basically the response to the patient’s symptoms/concerns, including the current treatment plan and any proposed changes to the intervention.
This is only a very brief outline of the type of information that is included within a clinical note, but it should give you a rough idea of what is required. One of the best ways to ensure you have included all of the relevant information is by using clinical note templates. These have been developed by healthcare practitioners to help improve the consistency, accuracy, and effectiveness of documentation. There are quite a few templates that you can choose from, and whilst they utilize different formats, they typically cover similar information.
SOAP notes are definitely the most commonly used template for healthcare practitioners of all different fields. They separate relevant information into four categories, each relating to a different aspect of a patient encounter.
Subjective: This section is focused on the patient’s subjective experience of their symptoms and how these have been impacting their day-to-day life. This may include comments on when the symptoms started, whether they have worsened and what impact they have had. Typically, a practitioner will use direct quotes from the patient within this section to illustrate their concerns.
Objective: The objective section of a SOAP note includes factual, objective data relating to the patient’s symptoms. This may include x-rays, scans, test results, measurements, and vital signs.
Assessment: The assessment section aims to combine the information provided in the subjective and objective components and reach a conclusion regarding the patient’s symptoms. This may mean including a possible diagnosis, any observed improvements, and commenting on the success of the current intervention.
Plan: Finally, the SOAP note concludes with a plan section, which outlines the specific short-term and long-term goals designed for the patient. The practitioner should also outline whether the treatment plan has had any adjustments, and when the patient should have their next appointment/session.
The DAP structure is fairly similar to the SOAP format, except it separates the content into three sections rather than four. Often, extremely busy practitioners or those who have limited time on their hands choose to use the DAP format, as it is typically considered to be simpler.
Data: The data section is sort of like a combination of the subjective and objective sections of a SOAP note. It should initially outline the symptoms experienced by the patient, and how these have affected their daily life, using direct quotations as support. It also commonly includes the practitioner’s subjective opinion on how the patient is presenting themselves, with comments on their behavior, appearance, and mood. Although clinical notes often include some form of opinion from the practitioner, it is essential that this is professional and can be supported by some form of evidence.
Assessment: This section is focused on the practitioner’s professional opinion of the symptoms and condition presented by the patient. It may include a statement on how the patient has responded to medication or treatment, and whether their condition has worsened or improved. The practitioner may also include a determined or probable diagnosis.
Plan: Finally, the DAP note concludes with a plan relating to the next steps in the patient’s treatment. This may include any changes to the current treatment plan, the introduction of a new intervention, medication, and the date of the next appointment.
BIRP is the final clinical note template that we’re going to cover in this guide, and similarly to SOAP notes, it separates information into four categories. Whilst the content of BIRP notes is similar to a SOAP note, it organizes information in a different way than certain practitioners may find preferable.
Behavior: The first section of a BIRP note focuses on the behavior of the patient, and the symptoms that they report experiencing. In addition to including direct quotes from the patient, the behavior section often incorporates the (professional) opinions of the practitioner. These subjective observations should be based on the patient’s mood, behaviors, and appearance and should be based on supporting evidence. When including opinions, the practitioner mustn’t use judgemental language or phrases that have negative connotations.
Intervention: This section is focused on drawing up a treatment plan and intervention for the patient, with emphasis on specific goals that the patient can achieve. The practitioner should also include what treatment methods they used during the session.
Response: This section focuses on the patient’s response to the treatment strategies during the session. The practitioner should discuss whether the intervention has been successful and the patient’s progress relative to their symptoms.
Plan: Once again, the conclusion of the clinical note should include a detailed plan of the next steps in treatment. This includes the specific date and time of the next session and the goals for the patient to achieve in between appointments.
Whilst the formatting structure of these templates differ, it is fairly evident that the content included within them is the same. As we mentioned, SOAP notes are the most commonly used template for healthcare practitioners, but you may find that a different structure works better for you. There is no right template to use for each healthcare profession, but we do recommend sticking to the same one. If you use the same template for all of your clinical notes, this will not only make the writing process much easier for you but consistent documentation has been shown to lead to more effective communication.
The impact of good clinical notes on the patient experience
We have already given a brief overview of the important role that clinical notes play in the healthcare industry, and now we’re going to dive a little deeper into the specific impacts that good documentation has on the patient experience.
In the past, many healthcare practitioners were taught to specifically focus on delivering their services as efficiently as possible. Whilst this still required effective treatment, a lot of the time it failed to adequately include patients within the healthcare process, leaving them to feel more like numbers than people. Obviously, many problematic issues arose out of this type of care, and there has been a significant shift to increasing inclusivity and transparency. These days, practitioners are being taught to balance their production of clinical documentation with a good patient experience; two concepts that are more interrelated than they have ever been before.
Step one to improving the patient experience with good clinical notes is related to patient access. Legally, patients are supposed to have access to their medical records, but this is an area that has never been properly achieved. In order to combat this, health regulation organizations are pushing providers to store their documents so they can be accessed much easier. One of the most effective ways of increasing accessibility is through the implementation of patient portals, a unique platform that a client can log onto and view their appointment, payment, and medical information. Increasing access to records and clinical notes can increase medication adherence and the success rate of preventative measures
An additional barrier preventing patients from engaging with their clinical notes has been the way that they are written. Although this is not necessarily the fault of practitioners, as they are simply writing what they know, most clinical notes are filled with medical jargon that the average patient would struggle to understand. Moving away from this type of language and ensuring that clinical notes can be easily understood will elevate the transparency of the treatment process and allow patients to be more involved in their care.
If practitioners focus on making their notes more understandable and accessible, research suggests that the overall patient experience will improve. Not only will patients engage more with looking after their own health, but communication with providers can be elevated. It is essential that patients feel comfortable raising any issues or concerns with their provider and establishing a safe and trusting relationship is the best way to facilitate this. Although we are not saying that writing good clinical notes will solve every problem in the healthcare industry, it has been shown that effective documentation improves patient satisfaction, engagement, and confidence with your services.
What leads to bad clinical notes?
This will seem like an incredibly obvious statement, but whilst good clinical notes lead to good outcomes, bad clinical notes do the opposite. It is unlikely that any healthcare practitioner would purposefully write poor documentation, but making mistakes is an inevitable part of doing anything. The best way to counteract these mistakes is being aware of the different issues that can contribute to poor clinical note-taking:
Lack of awareness: If practitioners aren’t properly aware of the role that clinical notes play in the healthcare field, then it is unlikely they will put in the effort to consistently create good documentation. And whilst ignorance isn’t an excuse, it is understandable that clinicians focus on the things that they know are important. As such, it is incredibly important that students training to become healthcare practitioners are taught why note-taking is such an essential aspect of working in the healthcare field. Additionally, regular training programs should be implemented into healthcare businesses to ensure that all staff members are kept informed about the most recent clinical note-taking guidelines.
Time: Time is perhaps the factor that most significantly influences poor clinical note-taking. The typical life of a healthcare practitioner is extremely busy, filled with back-to-back appointments and various required tasks. Although it is recommended that practitioners write their clinical notes immediately after a session with a patient, realistically this is not always possible. Nevertheless, given how important good clinical notes are, practitioners should focus on allocating a certain amount of time per week to writing their notes, ensuring that they aren’t rushed.
Habits: Many practitioners, particularly those who have been working for a long time, have habits that are hard to break. And whilst some habits are definitely good, others can have negative consequences. For example, we mentioned before that reducing the amount of medical jargon in clinical notes so that patients can better understand them has become increasingly important. Whilst this isn’t exactly a difficult change, it requires practitioners to be more thoughtful about the language they include, which requires extra effort. Working to change these habits may take a bit of time, but given the benefits that will arise out of improvements, this is definitely a task worth investing in.
We understand that as a healthcare practitioner, you don’t always have spare time to spend making sure that every clinical note is perfect. In saying that, the extent to which good notes will benefit both you and your patients illustrates just how important it is that you try and make them as effective as possible. Most of the factors that contribute to poor record-keeping are entirely avoidable, and it is the responsibility of the individual practitioner to ensure these mistakes occur as little as possible.
Clinical notes and compliance
Just as with every other area in healthcare, clinical notes are impacted by compliance. Medical compliance dictates the specific regulations and rules that healthcare providers must abide by to ensure they are delivering care legally and ethically.
Basically, there are different sets of regulations published by local, state, and federal institutions that all providers need to be aware of. Keeping informed about any recent changes in these regulations can prove tricky, especially given how prone they are to being updated. Nevertheless, as a healthcare practitioner, it is your responsibility to ensure you are aware of the current compliance rules and how they impact your work. Although it is not possible to cover everything related to medical compliance here, we will touch on the specific policies that impact clinical notes.
Before we begin looking at clinical note compliance, it is first necessary to introduce HIPAA. The Health Insurance Portability and Accountability Act is a set of federal laws that dictate how healthcare providers are required to handle patient information. Because clinical notes contain PHI (protected health information), specific rules dictate how they can be created, shared, stored, and destroyed.
The number one priority of HIPAA is to protect the privacy of patients, and this is taken very seriously. As such, if either a provider or a healthcare practice is found to be in breach of HIPAA regulations, the consequences can be severe. Depending on what tier the breach falls under, a provider can face between USD $100 to $100,000 fines, losing their license, or jail time. Additionally, HIPAA breaches can lead to patients losing trust in their providers and a significantly damaged reputation that can take years to rebuild. Whilst these consequences are definitely daunting, avoiding them is fairly easy provided you put the effort in to remain compliant.
After clinical notes have been written, HIPAA dictates that they must be stored in a secure location that has security measures in place. In the case of a breach, healthcare practices should have protocols that can be immediately enacted, aimed at preventing any further damage. Only authorized users should be able to access clinical notes, and patients should provide their consent if a practitioner wants to share or transfer confidential records. Whilst these policies may seem somewhat obvious, HIPAA breaches are still fairly common. The majority of errors made by healthcare practitioners are accidental, but they should still be avoided at all costs.
To help you understand what you should be focused on when evaluating your compliance strategies, we have compiled a list of some of the most common HIPAA breaches that impact clinical note-taking:
Sharing information in a non-secure way: Providers must use a platform that encrypts their data when they share records. Some of the most common HIPAA breaches occur when a provider attaches a patient’s clinical notes to an email or text message and shares it with another party. These platforms don’t utilize encryption and the data is at high risk of being hacked or leaked.
External providers: We’re going to explain more in-depth about the role of utilizing external software providers in healthcare, but basically, HIPAA dictates that when a healthcare business gives any type of patient data to an external provider, they are required to enter into a Business Associate Agreement. This agreement ensures that both parties are aware of their compliance responsibilities, and holds the external provider accountable in the case of a data leak.
Loss of device: Unfortunately, when a device that stores patient data is lost or stolen, this is considered a HIPAA breach. And whilst these situations cannot always be prevented, practitioners must be conscious of this risk and have security measures in place.
Incorrect disposal of clinical notes: When it comes time to dispose of clinical notes and patient records, this has to be done in the right way. Although the specific method is up to the practitioner, the data needs to be disposed of and left in an irreversibly destroyed state. Simply leaving paper records in a trash basket or on a hard drive increases the risk of the data falling into the wrong hands, which is a serious HIPAA violation.
How to avoid HIPAA breaches
Being aware of the most common HIPAA breaches will help you to fix any areas of improvement and remain legally and ethically compliant. Even though HIPAA breaches do occur, it is important to remember that they aren’t inevitable and with the right policies in place, you should be able to avoid them.
Training: One of the biggest causes of a HIPAA breach is a lack of education and training. If healthcare practitioners aren’t aware of regulations and how their behavior impacts patient security, then the risk of a breach increases significantly. To minimize these occurrences, it is a good idea to implement regular compliance training programs in your healthcare business. By ensuring that all practitioners and staff members are kept informed about the most recent HIPAA regulations, you can ensure that breaches are kept to a minimum.
Culture: Fostering a culture of compliance in the workplace is a highly effective strategy that reduces the risk of breaches. Encouraging staff members to prioritize compliance and raise any questions they have will lead to better practices. Additionally, it is important that practitioners feel comfortable if they are required to anonymously report the actions of a coworker or colleague. Whilst this is a situation that nobody wants to be in, potential HIPAA breaches must be investigated as early as possible, and the damage is repaired.
Audit: Different local, state, and federal compliance organizations run audits on healthcare businesses at random times. To ensure that you are always prepared for these situations, you should regularly conduct self-audits. The results of these will indicate to you if any areas require improvement, and you can focus on elevating your compliance policies.
Understanding everything about healthcare compliance takes a lot of time, and the specific regulations that apply to your work will be dependent on a variety of factors. In the above section, we briefly touched on how you are required to look after your clinical notes, but there is a whole lot of information that you still need to know. If you are interested in developing your understanding of medical compliance and HIPAA (which you should be), we recommend having a look at the following resources:
- Guide to Privacy and Security of Electronic Health Information: This is a basic overview of HIPAA guidelines. The website has links to training games and risk assessment tools.
- State Attorneys General: A more comprehensive overview of what HIPAA and HITECH entail.
- CMS HIPAA Basics for Providers: Details of the role that providers play in adhering to HIPAA compliance, with additional information on how the breach notification rules and possible consequences of non-compliance.
- World Health Organization: Catalog of resources to support health services delivery transformations.
Clinical note software
As technology advances and is being increasingly implemented into the healthcare industry, we are seeing the development of software designed to assist with certain tasks, including clinical notes. Whilst we understand that incorporating new systems can be scary, we believe the benefits offered by clinical note software should be embraced, regardless of what field of healthcare you work in.
There are different types of clinical note software that have been developed, and what suits your business may differ from what suits another business. The most simple forms of clinical note software provide an electronic platform upon which practitioners can create and store their clinical notes. Often, these systems are integrated with features designed to help the documentation process, including note templates and cloud-based storage.
By far the most popular form of technology that is used in the creation and storage of clinical notes is called EHR (electronic health records). In the last decade or so, the popularity of EHR systems has increased exponentially and it is currently very rare to find a healthcare practice not using EHR. At its most basic, EHR is a system designed to streamline the documentation process with the additional capability of securing and storing this data. However, EHRs have been developed to play a more involved role in the healthcare process, and can greatly improve patient outcomes.
Typically, these systems work by providing practitioners with an online method of creating clinical notes. Once written, they are stored in the database, where they can be accessed and shared by authorized users at any time. The most effective EHRs use cloud-based technology, which means that data is stored via remote servers, where it can be accessed from anywhere, at any time. One of the most significant benefits of using cloud-based EHRs is the way they facilitate effective communication between providers. We mentioned previously that clinical notes can be, and often are, shared between a patient’s caregivers as a way of ensuring that everyone is kept informed about treatment progress.
Unfortunately, there have been many instances of a patient receiving harmful treatments or medications due to miscommunication between providers, and figuring out a way to reduce the risk of poor inter-provider management has been a top priority of the healthcare industry. And this is where EHRs come in. Research conducted on the impacts of EHRs has repeatedly found that they not only improve communication, but also patient outcomes and the general productivity of a workplace.
If you are interested in reading more about EHRs and how they have impacted the healthcare industry, we recommend taking a look at this article:
Benefits of clinical note software
The vast benefits that clinical note software has for both practitioners and patients are reflected in its increasing popularity. Some of these advantages include:
Save time: Everyone knows that healthcare practitioners lead extremely busy lives, filled with appointments, consultations, and various administrative tasks. Any opportunity to save time should be seized, and note software offers the perfect solution. Practitioners will be able to significantly cut down on the time they spend on their documentation, without having to compromise quality or accuracy.
Increased organization: After clinical notes have been written, they must be stored in a secure and organized manner. As you know, these documents are frequently shared between third parties, including other healthcare providers and insurance companies. For communication and continuity of care to be effective, it is vital that providers can easily access and share their records. Utilizing cloud-based storage options provides the perfect solution for these situations, as individuals with authorization can securely access records at any time, from anywhere.
Easier billing process: The medical billing process is incredibly complicated, and healthcare businesses often find themselves having to deal with claim rejections and denials. Whilst using clinical note software won’t necessarily eliminate these hassles, they lead to more accurate documentation which in turn contributes to a faster billing process. Clinical note software can alert users to any errors or missing information in the records, helping to ensure that all patient records are as accurate as possible.
Data analytics: Looking after patients by having updated records and charts can be difficult, especially if this process is completed manually. Clinical note software can integrate and organize patient data for you and produce updated medical charts. In addition to this facilitating better treatment decisions and clinical outcomes, it also saves you time and optimizes your organization.
What to look for in clinical note software
Whilst the specific features included in your clinical note software will vary depending on the size of your business, your clientele, and the services you offer, there are a few universal functions that we recommend looking out for.
Storage capability: The exact amount of storage that you need will depend on the amount of data that your practice typically processes, but it is a good idea to be aware of a provider’s storage capabilities prior to signing up with them. Regardless of the size of your business, we definitely recommend paying for unlimited storage as this option gives your practice greater scalability and the chance to grow.
Medical dictation: One of the main purposes of using clinical note software is to improve productivity and save time for practitioners. Whilst all systems offer the ability to type clinical notes, which is a preferable method to hand-writing, it is in your best interest to look for medical dictation features. Using medical dictation is even faster than typing, and can also lead to notes with fewer errors.
Integration with other features: Often, clinical note software is integrated with a variety of features aimed at streamlining administrative tasks. Whether or not your healthcare business requires these features is dependent on the current management system in place, but it is definitely a good idea to look into what could potentially help. Amongst others, these features include appointment scheduling, medical billing and coding, video conferencing, and patient portals. By choosing an integrated system, your practice will be able to create a unified workflow, access patient data, and complete administrative tasks from a single, secure platform.
HIPAA compliance: We’re going to explain a little more in-depth about the compliance regulations required for healthcare software, but for now it is merely important to know that the system you choose needs to be HIPAA-compliant. As we mentioned earlier, it is also essential that you enter into a Business Associate Agreement to ensure each party is compliant.
Clinical note software compliance
Although we have already touched on the importance of compliance when it comes to clinical notes, it is necessary to briefly look at the specific compliance regulations that impact software. Pretty much every vendor that you look at will advertise that they are HIPAA-compliant, but you should still research their specific privacy policies to determine whether they are up to scratch.
Any information stored online comes under EPHI (electronic protected health information), making it subject to HIPAA’s Security Rule. This regulation dictates that EPHI needs to be protected with three safeguards:
The specific ways that a vendor or healthcare practice chooses to implement these three safeguards is basically up to them, but they must be appropriate and suitable for the type of EPHI that is being transmitted. Different vendors will apply different safeguards, but we’ve curated a list of some of the most commonly used security policies to give you an idea of what to look out for:
Administrative safeguards: Regularly performing a risk analysis of the current security procedures; evaluating the likelihood of a data breach/hack and implementing appropriate measures to counteract this risk.
Physical safeguards: Security at the physical location of the servers; alarm systems; device security protecting computers, phones, and tablets against unauthorized access.
Technical safeguards: access, audit, and integrity controls; security designed to protect data during the transmission process, including high-level encryption.
When you think you have found a suitable vendor to supply clinical note software, remember that you have to enter into a BAA (Business Associate Agreement). The BAA ensures that both the Covered Entity and the Business Associate are responsible for protecting the EPHI, and is an essential component of remaining HIPAA-compliant.
We understand that this information can seem overwhelming, but you must know the ins and outs of compliance in order to protect both your practice and your patients. If you are interested in learning more about healthcare compliance and what security measures you can implement, we recommend having a look at Ultimate Guide to Healthcare Compliance.
Tips for writing better clinical notes
Before we wrap up, we thought it would be useful for you if we gave you a list of tips you can employ to ensure your notes are as effective as possible. Everyone has their own preferences, and we recognize that some habits are hard to break, but it’s never too late to focus your time and energy on improving your clinical notes!
Timing: When you write your notes has a significant impact on their quality. It isn’t a good idea to write them during a session with a client, as this can be distracting for both patient and practitioner, but as soon as possible after is ideal. If you leave your notes for too long, it becomes more likely that you will forget critical details and/or become swamped with the pile-up of documents to write.
Thorough: There are different purposes for different types of clinical notes, but regardless of whether you are writing a progress note or a discharge form, you must be thorough. Rushing through them and skimming over important information increases the likelihood of errors within notes and poor communication, two scenarios you want to avoid.
Concise: Whilst being thorough is important, so is being concise. This doesn’t mean that you should exclude something important, but you should be conscious of the type of language you use. Eliminate any vague or repetitive phrases, and make sure that what you are saying is relevant and to the point.
Patient access: If a patient is granted access to their clinical notes, it is important that these can be easily shared. We’ve already touched on the importance of having easily accessible clinical notes for inter-provider communication, and this works the same for patients. One of the best ways to increase patient access to clinical notes is through the use of a patient portal; an electronic platform that clients can log onto and view their appointment, payment, and medical information.
Legibility: An obvious yet overlooked necessary component of clinical notes is that they must be legible! If you know that your handwriting isn’t the neatest, then it is a good idea to make the shift to electronic methods. Additionally, using an EHR or clinical note system will improve the organization of your notes and make them more accessible.
Trends impacting clinical notes
Just like every other area of healthcare, the processes of writing and storing clinical notes are highly fluid. With the increased implementation of healthcare software, we are seeing the emergence of certain trends. As we have already discussed, an increasing number of practices are using electronic systems to handle their notes. Also on the rise is systems that cater to mobile use. In the US, the vast majority of people have access to a smartphone, which they use in various ways during their day-to-day life. The healthcare industry is slowly adapting to this use by implementing systems that can be effectively utilized with mobile devices. At the moment, clinical note software often comes integrated with mobile health apps, allowing practitioners to complete their documentation on the go. These apps also give patients greater flexibility in accessing relevant information, including their medical records.
The other biggest trend that we are currently seeing is the shift to improve patient access to clinical notes. Although this is technically currently in play, patients are still struggling to gain easy access to their clinical notes and medical records. This is a difficult barrier to overcome, especially given the type of information that practitioners include in their notes, but it is nevertheless necessary to make the treatment process as transparent as possible. One of the best solutions for this is to implement a patient portal so that clients can very easily access documentation and raise any issues or concerns with their practitioners.
These changes to the healthcare industry can be daunting, especially if you are used to things working in a certain way. Nevertheless, they are trends that have arisen out of a desire to improve clinical note-taking, and as such should be fully embraced.
Clinical notes are an integral aspect of working as a healthcare practitioner and it can be difficult to wrap your head around all of the important aspects. We hope that now you have finished this guide, you are more confident with your understanding of why clinical notes are so important and what you can do to improve your record-keeping. Before we go, we’d like to leave you with one final recommendation: make the most of healthcare technology. These systems have been developed with your needs in mind and they are almost guaranteed to elevate your productivity and organization. They have also been shown to improve communication, treatment decisions, and clinical outcomes - what’s not to love?