From the Guidelines
Documentation is crucial in healthcare as it ensures continuity, safety, and quality of treatment by providing a comprehensive record of patient care. According to a policy position paper from the American College of Physicians 1, clinical documentation should support patient care and improve clinical outcomes through enhanced communication. This is achieved by including the patient's story in as much detail as required to retell the story, using macros and templates to improve completeness and efficiency, and facilitating thoughtful review of previously documented clinical information.
Some key aspects of effective documentation include:
- Defining professional standards regarding clinical documentation practices throughout organizations
- Redesigning clinical documentation based on consensus-driven professional standards unique to individual specialties
- Using the electronic health record (EHR) to facilitate thoughtful review of previously documented clinical information
- Implementing effective and ongoing EHR documentation training of clinical personnel
- Capturing structured data only where they are useful in care delivery or essential for quality assessment or reporting
Proper documentation provides a clear timeline of a patient's medical history, treatments, medications, allergies, and responses to interventions, allowing all healthcare providers to access critical information when making clinical decisions. For instance, documenting a patient's medication regimen, including dosages and any adverse reactions, enables healthcare providers to make informed decisions about future treatments. Effective documentation is essential for ensuring patient safety, preventing medical errors, and providing high-quality care. As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses 1.
From the Research
Importance of Documentation in Healthcare
Documentation in healthcare is crucial for several reasons, including:
- Maintaining continuity of care and informing health professionals of ongoing treatment 2
- Providing legal evidence 2
- Allowing patients to access their medical records and correct any inaccuracies 3
- Ensuring that patients understand written health information, which can be challenging due to complex medical terms and small print 4
Challenges in Documentation
Despite its importance, documentation in healthcare can be overwhelming for healthcare professionals, leading to:
- Occupational burnout due to excessive time spent on medical records 5
- A disincentive for healthcare professionals to provide high-quality care 5
- Challenges in making electronic health records accessible to patients, including cost and security concerns, liability issues, and tensions between flexible access to data and physicians 6
Benefits of Accurate Documentation
Accurate and clear documentation is essential for: