Common mistakes with clinical documentation writing - and how to avoid these

Clinical documentation is an essential and integral component of healthcare businesses, as it is used to note all patient medical information from a physician visit. Not only are you legally required to compose notes relating to any patient interaction and treatment, but clinical documents serve as a point of reference for future treatment, and can be accessed by authorized healthcare professionals. If a patient needs to be referred to another healthcare practice, the new doctor must have the ability to oversee patient information and quickly gain an accurate understanding of their health condition. Clinical documentation also serves as evidence in legal situations, where additional care support and medical reasoning may be required. Insurance companies may also need access to clinical documentation to ensure they are being billed the appropriate amount, and that the patient is eligible for the right coverage. 

Maintaining good clinical documentation can be difficult, and it is easy to make mistakes. Many healthcare businesses, such as Carepatron, provide clinical documentation for healthcare practices to help you compose and securely store notes and minimize the risk of incorrectly structured information. Clinical documentation is used by over 50 million US healthcare providers, and learning how to navigate them can greatly elevate the quality of your services.

We all make mistakes, however, failing to correct them can result in serious consequences for your healthcare practice, especially concerning malpractice allegations. To provide the highest level of care for you and your patients, you should consider the following common pitfalls and clinical note documentation errors. 

• Altered information - Records should be highly transparent and preserved at the time of their composition. Chart notes should never be tampered with, even in the case of adding notes. Failing to do so could result in malpractice, where a team of experts will have to evaluate your case. 
• Incorrect mistake processes - When you make a mistake, you should draw a line, then initial and date the corrected information. This way, you can clearly see the original content, what was added, and who conducted the mistake. Using white-out may lead to confusion and doubt about the contents of the mistake, and whether the information has been misconstrued. 
• Lack of dates - Medical documents can be accessed at any point in time, including years down the line. Hence, you must note the date and time, along with the patient’s information, for a clearer paper trail, and an easy way to identify when a patient was seen.
• Lack of signatures - There should always be initials on any medical record, as well as next to mistakes, to ensure that only authorized medical professionals have access to the right information. It is good practice management and ensures that they have been overseen and proofread. 
• Blank spaces -  Having blank spaces is highly inefficient and demonstrates a lack of professionality. Some blanks are acceptable, but if it is 90% blank, then more information or structuring is needed.
• Illegible records - Clinical documents must be able to be read and reviewed by fellow healthcare professionals, so it is important that if they are handwritten, they must have a proper level of care. Electronic clinical notes are strongly encouraged to avoid this, with typed notes ensuring the same level of understanding across practices. 
• Uncommon abbreviations -  While abbreviations can make processes super simple, they can also result in misinterpreted information. If you need to use abbreviations, it is best to use universal ones that carry a lower risk of being misunderstood.
• Lack of full documentation - When you compose clinical documentation, you should document any points of interaction, including non-compliant patients. This can be critical in the case you are accused of abandonment, as well as the fact that you need to document phone calls. Any advice or recommendations given can be held against you, so you must remain accountable and responsible. 
• Only charting abnormal results - While we tend to focus on healthcare issues, normal results must be also reported to eliminate any serious conditions. It can help practitioners narrow down conditions whilst providing solid medical reasoning for other healthcare professionals to evaluate. It inhibits treatment limitations, by considering all health possibilities. ‍
• Not considering your audience - In a healthcare practice, you need to ensure that your patients' needs are prioritized and addressed. Having targets in mind helps you align business and health goals, as well as ensure that you can support patients with effective treatment.

When it comes to writing effective clinical documentation notes, there are numerous do’s and don’ts that you should consider. Failure to recognize these aspects could result in less efficient clinical outcomes, as well as potential lawsuits. The best practices will consider these, and factor them into their practice for effective project planning.

Do’s 

• Have the right patient - It is easy to mix up patient charts and information when moving through healthcare facility processes, so it is important that you document the right information, in the right place.
• Document everything - Note the patient’s quotes, gestures, non-verbal cues, body language, and anything relevant to their health issues. Documenting all this information can provide a clearer picture of patient information, which is helpful for when other healthcare professionals review your records.
• Implement a good correction process - It is important that you draw a line through errors, as well as initial and date any mistakes so others know the original content, and who made the mistake. This is important for ensuring a clear correcting process that holds certain individuals accountable when needed.
  

Don’t

• Copy and paste - Using copy and paste shortcuts can lead to inaccurate information, and ineffective treatment. All records should be specific to the patient you are examining. 
• Cause delay - Make sure that you write clinical notes after the session, so you aren’t interrupting the patient, but it is also important to not leave it too late. Leaving clinical documentation until the last minute can cause critical information to be missed, which may be vital to effective treatment. ‍
• Be vague - General statements and terms, such as ‘fair’ and ‘normal’, can lead to miscommunication and misconstrued readings and examinations. Being concise and clear is the easiest way to ensure patient information is accurate and representative of their condition.

Clinical documentation can be an intricate process, and many factors need to be considered to ensure that you compose notes that are effective, and properly address patient conditions. It is easy to make mistakes, and quite frankly, we all make them, so understanding the common pitfalls of clinical documentation is vital to improving how you deliver healthcare in your practice. Many businesses, such as Carepatron, offer clinical documentation resources and templates embedded within encrypted software, to support you in improving clinical documentation methods. It is an easy way to elevate the quality of your service, as well as protect patient information so only authorized healthcare professionals can review and assess it. 

Further reading:

• Preventing Healthcare's Top Four Documentation Disasters
• Top 5 2021 Coding and Health Care Data Articles from Chiropractic Economics