Guidelines On Writing Best Practice Clinical Documentation

Clinical documentation is an essential component of successful healthcare practices, referring to recording information concerning patient health conditions, symptoms, diagnosis, and treatment.

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Overview of clinical documentation

Overview of clinical documentation

Clinical documentation is an essential component of successful healthcare practices, referring to the recording of information concerning patient health conditions, symptoms, diagnosis, and treatment. It ensures that patient information is up-to-date, and properly represents the patient’s state of health, with efficient clinical notes serving as excellent points of reference for future treatment. Used by over 50 million healthcare practitioners in the US, clinical documentation is vital to the success of your practice, whilst also ensuring HIPAA and legal compliance. In the case of lawsuits or legal issues, clinical notes can provide evidence of medical reasoning, and can also guarantee that insurance companies compose appropriate medical bills and codes. 
Because clinical documents can be accessed by authorized healthcare professionals, and are likely to be reviewed, you must implement the best documentation methodologies and practices. Some businesses, such as Carepatron, provide clinical documentation for healthcare teams, that support you with embedded templates and resources to increase accuracy in your notes. Following clinical documentation guidelines, you can greatly elevate the quality of your practice and improve clinical outcomes for your patients.

Most common uses of clinical documentation

Given that clinical records serve multiple purposes for your healthcare practice, the documentation process is not as simple as writing down patient medical information. Some of the purposes or documentation include:

  • Communication - Clinical documents are an excellent way to provide information to multiple healthcare providers, across organizations. It allows for organized notes, with a universal structure for easy comprehension. Because they are standardized, they are a highly efficient form of record-keeping for efficient health clinics.
  • Legal compliance - Clinical notes are essential to serve as evidence in the case of legal issues and matters. It holds practices accountable and responsible for the accuracy of their information, as failing to be compliant may result in lawsuits, regulation concerns, as well as other costly legal pursuits. 
  • Reimbursement - Medical coding and billing practices may use clinical documentation to compose bills for reimbursement from insurance providers. The quality of care provided can determine the amount given, and so all information must be accurate.  
  • Quality assessment - Clinical documents serve as a great way to measure performance outcomes in accordance with healthcare standards, as well as to analyze business processes regarding guidelines that should be followed. Identifying weaknesses in clinical notes are a great starting point for improving healthcare performance, and thus, boosting profitability, productivity, and overall growth. 
  • Research - Patient information collected from clinical documentation can contribute towards overall improvements in healthcare, and increasing accuracy of treatment.
Most common uses of clinical documentation
Commonly accepted guidelines for medical record documentation

Commonly accepted guidelines for medical record documentation

It is important to have structured documents that adhere to medical record documentation guidelines, as to produce highly consistent notes, and ensure a high quality of care. While many healthcare business practices may compose clinical documents differently, some essential elements are commonly accepted and should be incorporated. 

  • Include essential patient information - Each piece of clinical documentation should be unique to the patient and contain important information such as their name, ID, physical address, email, home and work telephone numbers, marital status, and employer. Doing so will minimize the risks of information becoming mixed up, saving time and increasing patient satisfaction. 
  • Make the author known - It should be very obvious who has written the clinical note, and they need to be signified with signed initials or a unique ID. The same goes for mistakes, and all errors should be marked with initials and a time stamp to show who made them. In the case of a review, professionals can better understand who is responsible with a direct link to the author of the document.
  • Note dates - All dates of patient interaction should be recorded, as this allows for easier traceability, and provides a higher level of accountability for responsible persons. 
  • Make them legible - Because multiple healthcare professionals may need to assess and refer to your clinical documents, you need to ensure they are legible. Doctors are notoriously known for poor handwriting, which can lead to misdiagnosis and ineffective treatments. It is advised to use electronic note methods to minimize these risks, as typed notes present information clearly and concisely. 
  • Medical history is identified - You must note any accidents, operations, immunizations, or illnesses that the patient has been subjected to, as well as any medication allergies and adverse reactions. This is vital in working towards an effective treatment plan, as it needs to coincide with the unique health of the patient. 
  • Subjective and objective information is included - You must represent both sides of the patient’s history, which includes subjective information concerning what the patient is experiencing, as well as objective evidence to support what is being seen. This may include laboratory results, examinations, and vital signs to indicate symptoms that the patient has outlined.
  • Consistent treatment plans - Although it may seem obvious, having treatment plans that align with the presented patient symptoms is vital. Other healthcare professionals should be able to review your notes and see a transparent process of how you reached certain medical conclusions to verify accurate medical reasoning. 
  • Follow-up care is recorded - Clinical documentation outlines all points of interaction, which includes any follow-ups. All communication that is relevant to the patient’s health needs to be noted for both legal purposes, and the patient’s coordination of care.

Tips for Clinical Documentation Improvement (CDI)

CDI programs focus on improving clinical documentation, as well as associated coding, billing, and reimbursement processes. Clinical documents should be consistent with universal documenting guidelines and should be high-quality to reflect clinician professional judgment and evaluation without dispute. CDI is vital to the success of healthcare businesses, and to execute documents well, aspects of CDI should be incorporated into your practice. 

  • Be specific - You should avoid vague and general statements so information is not miscommunicated and misconstrued. This way, healthcare professionals cannot make any inferences or speculations, with specific evidence dispelling any obscurities. 
  • Avoid jargon - Jargon can also contribute to misinformation, so it is best to use plain language and minimal abbreviations. If needed, you could use universal abbreviations that are standardized and less likely to be misinterpreted. 
  • Use dates - Always include dates on every document to identify every point of interaction between you and your patient. 
  • Include personal information - The more personal information included, the more effective treatment is likely to be. Other healthcare professionals can advise on what is best based on the unique history of the patient, which allows for higher satisfaction of care. 

Take home message

Good clinical documentation has its nuances, but with the right knowledge and resources, managing these notes can prove highly beneficial for your practice. In addition to having CDI processes in place, you can ensure that patient information is up-to-date, contains relevant and specific information, as well as tailored to their health needs. Excellent clinical notes serve as the basis for high-quality treatment that addresses and alleviates patient symptoms, no matter their nature. Carepatron is the leading option for you to follow clinical documentation guidelines, and ensure that you are prioritizing an increased level of care and coordination. 

Further reading:

Tips for Clinical Documentation Improvement (CDI)

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