Examples of Good Clinical Documentation

Clinical documentation is an integral aspect of working as a healthcare professional. As a physician, you must create records that relate to the medical treatment of any patient that you see.

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What is clinical documentation?

What is clinical documentation?

Clinical documentation is an integral aspect of working as a healthcare professional. As a physician, you are required to create records that relate to the medical treatment of any patient that you see. These notes are often used as references in instances of inter-provider communication and can facilitate effective continuity of care. Clinical notes are also used as evidence in legal situations or by insurance companies, so maintaining good documentation can protect your practice, and ensure you receive reimbursement for your services. 

Writing good clinical notes has various advantages for both you and your patient, regardless of what field of healthcare you work in. Different practitioners have their own preferences for how they create their notes, and can decide whether to use digital or analog documentation methods. To guarantee that your notes will effectively benefit you and your patients, they need to be consistent, timely, and accurate. Whether you are a general practitioner, nurse, psychologist, or therapist, improving your clinical documentation is always in your best interest, and that’s where we can help!

Fundamentals of medical records documentation

Writing poor medical records not only has negative implications in regards to legality and insurance, but they are a breach of proper duty of care. Ensuring that your patient is receiving the best treatment should be the absolute primary objective of delivering healthcare services, and this is heavily assisted by clinical documentation. To consolidate your understanding of what constitutes a good clinical note, we have collated some of the basic principles that should always be incorporated. 

Firstly, it is important to provide an explanation of both the risks and the benefits associated with a treatment decision. For example, if a physician decides to medicate a patient, not only do they need to outline the associated risks, such as their aversive side effects, but they should describe the benefits of the medication and the risks of not taking the medication. 

Secondly, you must include references to your clinical judgment. This may seem obvious, but as someone with both objective and subjective perceptions, all of your decisions need to be backed up by clinical reasoning. If it is determined you made a false decision, as long as your mistake was based on logical clinical reasoning, it is unlikely to be determined as negligent. 

Lastly, your documentation needs to refer to the patient’s capacity to understand their own role in managing their care. This means you should record whether the patient understands any potential side effects of medication, the symptoms they may experience, what constitutes a medical emergency and whether they know who to contact in the case of said emergency. Including these three guiding principles into your medical records will guarantee they are concise, consistent, and serve as adequate protection against any possible lawsuit.

Fundamentals of medical records documentation
4 examples of good clinical documentation

4 examples of good clinical documentation

Depending on your preference as a physician, there are different format templates you can use to create your notes. You also have the choice of whether to hand-write them or use an electronic method. Any of these options are perfectly suitable, as long as the information contained is accurate, consistent, and concise. So what exactly does a good clinical note look like? To make writing clinical notes as easy as possible, we have compiled a selection of 4 examples of good documentation that follow the SIRP (situation, intervention, response, plan) format.

Example 1:

  • Situation (S): The client participated in group therapy with 8 peers and 2 facilitators. The group aims to provide a safe space where clients can work on the following goals: increased peer social skills, decreased isolation and interpersonal skills. The client stated that he felt “better” and appeared attentive.
  • Intervention (I): Facilitators explained how exercise can positively impact physical and emotional health. The group was encouraged to collectively decide on a physical exercise that they consequently completed. Facilitators and peers encouraged each other to complete the activities.
  • Response (R): The client actively participated in the decision-making process by offering exercise suggestions. The client completed activities and encouraged peers to do the same.
  • Progress (P): Continue with weekly group therapy sessions. Encourage and support the client’s goals.

Example 2

  • Situation (S): Focus of the session was aimed at introducing new coping skills to manage depression and anxiety. The client appeared despondent, indicated by minimal conversation and stating “I don’t think I’m getting any better, I just wish I was happy”.
  • Intervention (I): Clinician attempted to engage the client in the discussion by asking about her weekend and whether she achieved her goal of going for 2 walks in the past week. Client was introduced to journaling as a method of releasing some emotion, and encouraged to attend group therapy sessions and reach out for help if needed.
  • Response (R): Client said her weekend was “fine” and said she achieved her goal of going for 2 walks. Client appeared reluctant to begin journaling but agreed to attend group therapy.
  • Progress (P): Client to continue twice-weekly therapy sessions. These sessions will continue to focus on introducing coping methods.

Example 3

  • Situation (S): This was the client’s first session and he expressed issues with feelings of anxiety, particularly at work. Client stated that he “felt overlooked and unconfident”. He says his feelings of low worth are impacting his home life. The client was alert and attentive during the session.
  • Intervention (I): Client was taught coping mechanisms, including ways to remove himself from stressful situations where appropriate. Client was encouraged to reach out to his partner and tell her about how he is feeling.
  • Response (R): Client stated he would talk to his partner this week about the difficulties at work, and would try and implement new ways of coping with workplace troubles.
  • Progress (P): The client will work on problem-solving at work this week. He is to continue these sessions weekly.

Example 4

  • Situation (S): Client continues to display serious signs of anxiety. Despite the introduction to different coping strategies, the client struggles to complete daily tasks, including going to the supermarket and socializing. Client appeared downcast, indicated by slow responses and speaking in a hushed voice.
  • Intervention (I): The clinician attempted to engage the client in formulating a new goal. Clinician validated the client's anxious feelings and reinforced previously taught coping mechanisms.
  • Response (R): Client created a new goal of socializing once a week with a trusted friend or family member. 
  • Progress (P): Client does not seem to be improving since previous sessions. Client will continue to come into the clinic once weekly and will consider increasing the dosage of the current medication.

Take home message

As you know, writing good clinical documentation has significant benefits for both physicians and patients. However, finding the time to maintain the consistency and accuracy of these notes is often difficult for physicians with busy schedules. To help you stay on top of this, we recommend using clinical documentation software. Carepatron offers a sophisticated system that provides various templates, including SOAP and DAP, that will cut down on the time you spend writing whilst still ensuring your notes are as effective as possible. Streamlining clinical note-taking will increase your efficiency and save you countless hours that can instead be spent doing what you do best: seeing patients!

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