What are the dos and don'ts of health documentation?

From the Guidelines

Health documentation should prioritize accuracy, completeness, timeliness, and objectivity, with a focus on concise, history-rich notes that reflect patient information and care plans. When documenting patient information, it is essential to include vital signs, medications with specific names and dosages, treatments provided, and patient responses in a chronological manner [ 1 ]. The use of clear, professional language and avoidance of abbreviations that could be misinterpreted are crucial [ 1 ].

Key Principles of Health Documentation

• Document patient information chronologically
• Include vital signs, medications, treatments, and patient responses
• Use clear, professional language and avoid misinterpretable abbreviations
• Document conversations with patients, especially regarding consent and education
• Avoid delaying documentation to prevent errors from faded memory

Electronic Health Records (EHRs) Considerations

• Follow institution's protocols for electronic signatures, templates, and copy-paste functions
• Ensure EHR documentation is concise, history-rich, and reflects patient care plans
• Avoid generating longer-than-necessary notes and propagate imprecise or incorrect documentation [ 1 ]

Best Practices for Documentation

• Never falsify records or include subjective judgments about patients
• Avoid using vague terminology that could be interpreted differently by others
• Refrain from documenting personal opinions or defensive notes in response to patient complaints
• Always follow proper amendment procedures for altering previous documentation, which typically require striking through errors with a single line, initialing, and dating the change [ 1 ].

By prioritizing these principles and best practices, healthcare providers can ensure that health documentation supports continuity of care, provides legal protection, facilitates communication between healthcare providers, and supports billing and reimbursement processes, ultimately improving patient outcomes and quality of life.

From the Research

Importance of Health Documentation

• Good documentation is essential for good medical care and can serve as a defense tool in case of medical malpractice claims 2
• Accurate documentation maintains continuity and informs health professionals of ongoing care and treatment, providing legal evidence 3

Strategies for Improving Documentation

• Develop a list of commonly underdocumented or incorrectly documented clinical conditions and educate clinicians on definitions 4
• Measure and manage documentation performance to improve accuracy and thoroughness 4
• Consider the roles of electronic health records (EHRs), patients, and clinicians in improving documentation 5

Quality of Health Documentation

• Most issues initiated by patients in discussion are often omitted from notes, and nearly half of notes refer to unverifiable information 5
• Documentation quality varies depending on the measure, with room for improvement in most domains 6
• Certain physician and patient characteristics correlate with measures of documentation quality, but no pattern emerges 6

Best Practices for Health Documentation

• Ensure accuracy, thoroughness, and quality of documentation 3, 5
• Use EHRs to accelerate documentation and enhance details of notes, while minimizing errors 5
• Regularly review and assess documentation quality to identify areas for improvement 4, 6