A Complete Cheat Sheet for Clinical Documentation

What is clinical documentation in healthcare?

Clinical documentation refers to the creation of medical records that pertain to patient healthcare. It is the primary method of tracking a patient's health status, documenting medical necessity, and supporting continuity of care. This systematic process includes recording essential components such as patient complaints, diagnostic findings, treatment plans, and progress notes in an inpatient or outpatient setting.

The documentation process also extends beyond basic record-keeping. It is crucial for facilitating communication among healthcare providers, supporting medical billing and coding procedures, and making healthcare more accessible. Because of their accessibility, clinical documents can be easily understood by most healthcare users, and with one glance, healthcare providers can gain insight into patient treatment. In the case of a lawsuit, clinical documents also serve as sufficient medical reasoning and credit your practice with authority and reputation. 

How can private practitioners improve their clinical documentation skills?

While every practitioner writing something will have their own methods for writing documentation, here are some helpful and valuable strategies for clinical documentation improvement:

Standardize your notes

Certain guidelines relevant to your industry apply to clinical documentation. Sticking to these standards will save time when creating your documentation, ensure accurate records, and ensure that your notes are easy to read.

Take inspiration from others

Numerous practitioners in your field are known for their fantastic documentation. Reviewing medical record documentation by others can be a good practice. Look at how they take their notes, and don't be afraid to ask for advice. 

Feedback

One of the best ways to improve any skill is to ask for feedback. If your documentation needs to be shared with other practitioners, ask them how they found your notes. Were they readable? Easily navigated? Organized? 

The basics of clinical documentation

Despite every healthcare practice conducting clinical documents differently, there is a basic structure thought process that you should adhere to to receive the highest level of care for your patients. You should be incorporating the following features to create good clinical notes:

• Include date and times: To properly piece together information in a clinical record, document the time and date on each patient note. 
• Write signatures: You must sign each client information page and write your name and role on any documented interaction. This ensures individuals know who is attending to certain patients and, in the case of legal issues, who is responsible. 
• Make timely entries: In improving clinical documentation, it is helpful to make sure you compose entries promptly to avoid missing out on critical information. It is equally important not to write them during your sessions, as this can interfere with your client and be perceived as rude.
• Be legible: Because other healthcare professionals are reading through your documents, they should be typed electronically to avoid miscommunication. If handwritten, extra care must be taken to ensure they are legible and clear. 
• Avoid abbreviations: Unless they are universal, abbreviations should be avoided to minimize the risk of misconstrued information. 

What is a clinical documentation cheat sheet?

A Clinical Documentation Cheat Sheet is a guide designed for healthcare professionals to streamline patient encounter documentation. This tool condenses the essential elements of clinical documentation into a quick-reference format, enabling providers to record accurate and comprehensive patient information efficiently.

The cheat sheet ensures that all relevant data is consistently captured during each patient visit, facilitating clear communication among healthcare team members and contributing to the continuity of patient care. By using a clinical cheat sheet often, providers can enhance the quality of clinical documentation, save time, and improve overall patient management. The following information can be helpful to include as you create your own cheat sheet.

Essential elements of good clinical documentation

Regardless of your healthcare field, all clinical documentation has some essential components. These include the following:

Correct credentials and information

All clinical documentation for certain patients needs to include the correct credentials of the relevant provider. Clinical notes also need to have the name of the patient they are referring to, and this information should be stored in the patient's files.

Diagnostic statement

Clinical documentation should include a statement regarding the patient's current and past diagnosis where necessary. This type of statement should also cover how the patient was diagnosed, the impact of the diagnosis, and any relevant progression that has been clinically observed.

Diagnostic methodology

The methodology contributing to the diagnosis is very important. The provider needs to explain the tests, assessments, evaluations, observations, and diagnostic criteria that have been applied. If the assessments used are non-formal, the provider must explain why these were used. 

Tips for an effective clinical documentation

To hone in on what makes clinical documentation effective, there are numerous strategies you should implement to elevate the quality of your client service. Doing so will increase patient satisfaction and improve patient care outcomes. We've curated some helpful tips for you:

Report critical values

Remember to always report critical values to a nurse within 15 minutes of the data being verified by the lab. Failure to do so can delay treatment, which is detrimental to the patient. They should also be reported to physicians within 30 minutes.

Avoid general information and statements

Each clinical document needs to be specific to the patient, and any general statements can easily be misconstrued. For example, simply stating that the patient called is inadequate is confusing. You need to specify whether the patient needs a return call or has a concern or query.

Accommodate your busy times

Even at your busiest time of day, you need to be aware of critical codes and transfers, shift changes, and different medication and physician orders. Despite how large your load is, you should not miss these vital details. 

Correct documentation methods

Your documents should be highly accurate regarding the patient's experience and composed in a legible format so any healthcare professional can pick them up and understand the patient's condition.

They should also include the subjective perspective of patient symptoms and objective observations. All notes should be professional, using correct spelling, grammar, and tone, and without personal judgment.

Efficient charting procedures

No charting should ever be completed in advance. Patient assessment must be carefully documented, and with the right nursing policies consulted, these should elevate the quality of your notes. 

Examples of good clinical documents

To help you visualize a good clinical document, we've included an example of a progress note separated into five sections.

This template is based on a SOAP format, which can be used to standardize and organize your notes. 

Demographic information

Date of session: 12/07/2022

Session duration: 50 minutes

Patient name: Jane Smith 

Patient number: XXXXXX

Subjective

Miss Smith reports continued feelings of depression. She describes her symptoms as having worsened, saying, “I find it hard to get out of bed every day.”

She is disinterested in her work and no longer enjoys her hobbies, saying she “doesn't see the point.” Miss Smith also reports feeling symptoms of anxiety and struggles to socialize with friends and family. 

Objective

Miss Smith had slow verbal responses during the session. She struggled to maintain a conversation, and her speech had a flat effect.

Her compliance with medication is good, but there are no evident improvements. Eating patterns are irregular, but weight remains unchanged. She reported having difficulty falling and staying asleep. 

Assessment

Miss Smith appears unfocused and disinterested. Her participation has decreased since her last session, and she struggles to maintain conversation and appropriately respond to questions and prompts.

Although Miss Smith is compliant with medication, it has not had an observable effect. Suicidal ideas or intentions were not expressed and did not appear present. 

Plan

Miss Smith is undergoing CBT to alleviate depressive symptoms. Medication will remain unchanged for the next 14 days. Miss Smith will be referred to a psychiatrist if no progress is observed.

Miss Smith will continue to attend weekly therapy sessions. She has been instructed to practice replacing negative self-talk with positive self-talk and has set a goal to go for two walks between sessions. 

The above examples should illustrate the type of information to include in your documentation and how this can be formatted. Every provider has their preference for how they write their documentation, and while this is perfectly fine, you need to ensure all the right information is included.

Final thoughts

Clinical documentation is the foundation for delivering high-quality healthcare services while maintaining professional and legal standards.

When approached systematically and with attention to detail, good clinical documentation protects healthcare providers and organizations and directly contributes to improved patient outcomes. Maintaining accurate, timely, and thorough documentation helps providers focus on what matters most - delivering exceptional patient care while meeting the evolving demands of modern healthcare delivery.