What is patient documentation?

Patient documentation refers to the recording of encounters and treatment of a patient. These records include various information pertaining to a client, including their past medical history, diagnoses, medication, and current treatment plan. Amongst other uses, patient documentation is necessary so that healthcare providers are equipped with all of the information required to treat a patient appropriately. These documents need to be consistent, timely, and accurate to ensure that they effectively inform practitioners, increase the quality of care and improve the reimbursement process. Importantly, most medical records are also legal documents, meaning that they can be used as evidence in the unfortunate instance of a malpractice lawsuit.

Given the various applications of patient documentation, it is always in your best interest as a physician to improve your clinical notes. One of the most effective ways to streamline clinical documentation and guarantee consistency is by implementing EHR into your practice. The effectiveness of using EHRs is reflected in the growth rate of healthcare businesses, as in 2018, it was reported that they were utilized by 78.7% of office-based physicians. Although there will be differences in how practitioners choose to record their documentation, we have collated some of the key strategies any healthcare professional can employ to maximize the effectiveness of their patient records.

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Importance of high-quality clinical documentation across healthcare

You will likely have been informed of the importance of maintaining high-quality clinical documentation. In order to consolidate your understanding and encourage you to improve your notes, we have compiled some of the key reasons behind why clinical documentation is so important:

Continuity of care: Often, a patient’s experience with the healthcare industry will span across several providers, departments and facilities. In order for the continuity of care to be effective, every healthcare provider needs to have access to pertinent information that will affect treatment. Essentially, if an external provider who has had no contact with the relevant client reads your clinical notes, they should be able to follow your reasoning and understand your treatment decisions. Further, patients who are transferred between facilities, or are discharged from inpatient care, need to be able to rely on their new provider. These transfers often happen quickly, and providers shouldn’t have to spend their time interpreting confusing or inaccurate notes.
Decision-making: Making difficult decisions is often a significant aspect of working as a healthcare professional. Good decisions have the ability to positively impact a patient’s wellbeing, whereas the effects of a poor decision can be extremely costly. One of the most effective ways to ensure you are making the right decision for a patient’s health is by being fully informed. This means that you need to know every detail that could impact your decision-making process, including the client’s medical history, medications, allergies, and treatment plans. With effective clinical documentation, you can feel confident that you are equipped with all the information required to treat the patient to the best of your ability.
Legal contexts: As previously mentioned, clinical records are often legal documents. Although protecting yourself against a lawsuit shouldn’t be the main driving factor for keeping good documentation, it is important to recognize that these situations do occur, and it is best to be prepared. If you include the treatment of a patient and professional reasoning behind your decisions, it is unlikely you will be deemed negligent.
Insurance: Managing insurance claims and reimbursement is becoming increasingly complex, and often you will find the time it takes between billing claims and receiving payment is lengthy. Further, any claims that have errors or inaccuracies will be rejected or denied, significantly extending the reimbursement process. Although it is difficult to completely eradicate these mistakes, producing high-quality clinical documentation can significantly reduce them.

Technological advancements in recent years have led to the development of software for healthcare businesses that can streamline your clinical documentation and guarantee consistency. Regardless of the field of healthcare that you work in, implementing these systems will elevate the efficiency and productivity of your practice, all whilst improving patient care.

What does high-quality documentation look like?

Although clinical documentation will look different depending on the field of healthcare that you work in, the size of your practice, and how many clients you see, there are certain features evident within all high-quality notes. Some guiding principles that you should keep in the forefront of your mind when creating your clinical documentation include:

Patient-centered: Although it is the physician’s responsibility to document patient records, it is important that they are patient-centered. This means that the patient’s goals of care underlie all treatment decisions.

Compliant: Just like all other aspects of working as a healthcare professional, keeping clinical documentation needs to be medically compliant. This means abiding by HIPAA guidelines and any other regulations that are applicable.

Up-to-date: All clinical documentation needs to be up-to-date, to ensure that good continuity of care can be achieved. It is highly recommended that physicians write their clinical notes immediately following a session with a client. Not only will this guarantee that records are up-to-date, but it also allows for the highest degree of accuracy.

Accessible: Given how frequently clinical documentation is shared between healthcare providers and insurance companies, it is important that they are easily accessed. We recommend you store them using cloud-based technology, which allows authorized users to access them from anywhere, at any time.

Tips to make your clinical documentation better

Now that you understand the different uses of clinical records and why they are so important, it is time to look at specific strategies you can use to improve your documentation.

The sooner, the better: Whilst writing your notes during a session can reflect poorly on your professionalism and lead to distraction, it is extremely important not to leave your documentation too late. Accuracy is one of the most essential requirements of writing good documentation, and completing your notes after a session will guarantee the information is still fresh in your mind.

Quality over quantity: This is particularly important if you are writing progress notes. Although you want your documentation to be thorough, lengthy notes can be hard to digest. Avoid vague language and be as concise as possible.

Legible: Although it seems obvious, legibility is occasionally overlooked. We definitely recommend creating your documentation electronically so that legibility is guaranteed. However, if you prefer handwritten notes, make sure that your writing is neat and organized.

Use a format: There are various templates available that can help organize your notes effectively. The most commonly used of these is SOAP, which separates information into subjective, objective, assessment, and plan sections.

Take home message

As the healthcare industry shifts to more value-based care, writing effective clinical documentation is becoming increasingly important. These records not only assist with insurance and reimbursement, but have been proven to elevate the quality of care and improve clinical outcomes. One of the most effective ways to increase the quality of your practice’s documentation is by implementing healthcare software like Carepatron. Carepatron offers a fully integrated, HIPAA-compliant platform perfect for any healthcare professionals. You can use note templates to improve consistency, before secure storage with cloud-based technology. Streamlining the clinical documentation process with this system will not only save your practice hundreds of hours, but it will help improve patient quality of care.