What is the recommended method for documenting patient findings?

From the Guidelines

The recommended method for documenting patient findings is the SOAP note format (Subjective, Objective, Assessment, Plan). This structured approach begins with recording the patient's subjective complaints and history, followed by objective measurements and examination findings, then the clinician's assessment or diagnosis, and finally the treatment plan. Documentation should be clear, concise, and chronological, avoiding abbreviations that aren't widely recognized. All entries should be dated, timed, and signed with the provider's name and credentials. Electronic health records (EHRs) have become the standard for documentation, offering templates that guide comprehensive documentation while ensuring legibility and accessibility. Thorough documentation is essential not only for continuity of care but also for legal protection, quality improvement, and reimbursement purposes. The information recorded should be factual, relevant, and specific enough that another provider could understand the patient's condition and continue care seamlessly based on the documentation alone 1.

Key Considerations for Documentation

• The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication 1.
• Physicians working with their care delivery organizations, medical societies, and others should define professional standards regarding clinical documentation practices throughout their organizations 1.
• The clinical record should include the patient's story in as much detail as is required to retell the story, and when used appropriately, macros and templates may be valuable in improving the completeness and efficiency of documentation 1.
• The EHR should facilitate thoughtful review of previously documented clinical information, and ready review of prior relevant information may be valuable in improving the completeness of documentation as well as establishing context 1.

Best Practices for Electronic Health Records (EHRs)

• EHRs should support links to the sources of the data being referenced to provide attribution and the ability to trace the information to the original author 1.
• Clinical documentation is not improved by the use of nonstandard terminology or forced uniqueness, and it is best served by brevity and thoughtfulness, efficiently conveying findings, thought processes, decisions, shared decisions, actions taken, and where appropriate, actions not taken 1.
• The use of structured data can be valuable for certain types of information, but not all clinical data lend themselves to structured documentation, and the act of entering coded observations into a record can be slow and awkward by nature 1.

From the Research

Documenting Patient Findings

To document patient findings effectively, the following methods are recommended:

• Use of standardized nursing terminologies and computerized records to structure nursing documentation 2
• Implementation of templates for uniform data documentation and reporting in critical care using a modified nominal group technique 3
• Adoption of structured and standardized documentation to improve the quality of notes in the Electronic Health Record 4
• Utilization of standardized forms to improve the documentation of quality of care 5
• Standardization of the surgical pathology report using formats, templates, and synoptic reports 6

Benefits of Standardized Documentation

The benefits of standardized documentation include:

• Improved content and completeness of documented nursing care 2
• Increased quality of evidence and enhanced large international multi-centre studies 3
• Significant increase in note quality and clarity 4
• Higher documentation rates of quality measures 5
• Uniformity and consistency of included data relevant to clinical management of patients 6

Best Practices for Documentation

Best practices for documentation include:

• Using computerized nursing care plans to increase documentation completeness 2
• Developing templates for documenting and scientific reporting using a modified nominal group technique 3
• Implementing structured and standardized documentation into the Electronic Health Record 4
• Using fully standardized templates to dictate or collect operative and history information 5
• Standardizing the surgical pathology report using formats, templates, and synoptic reports 6