What other important documentation should be prioritized for patients with complex medical conditions?

Important Documentation for Patients with Complex Medical Conditions

For patients with complex medical conditions, comprehensive documentation should include a patient treatment plan that prioritizes goals, outlines intervention strategies for risk reduction, and includes a discharge/follow-up plan that reflects progress toward goals and guides long-term secondary prevention plans. 1

Core Documentation Components

1. Medical History Documentation

• Complete review of current and prior medical diagnoses and procedures
• Documentation of comorbidities (peripheral arterial disease, cerebrovascular disease, pulmonary disease, kidney disease, diabetes, musculoskeletal disorders, depression)
• Medication documentation including dose, frequency, and compliance
• Date of most recent vaccinations
• Cardiovascular risk profile
• Educational barriers and preferences 1

2. Physical Examination Documentation

• Cardiopulmonary systems assessment (pulse rate/regularity, blood pressure, heart/lung auscultation)
• Post-procedure wound sites
• Orthopedic and neuromuscular status
• Cognitive function assessment 1

3. Medication Reconciliation

• Document that the patient is taking appropriate evidence-based medications
• Document medication allergies and adverse drug reactions with specific details
• Ensure allergies are prominently displayed in the medical record 1
• Document reasons for medication non-adherence or contraindications 1

4. Advance Care Planning Documentation

• Document patient's health goals and preferences
• Include advance directives, durable power of attorney for healthcare
• Document code status orders and POLST (Physician Orders for Life Sustaining Treatment) forms
• Place advance care planning documentation in easily accessible, centralized locations in the EHR, not buried in progress notes 2, 3

Documentation for Transitions of Care

1. Medical Transfer Summary

For patients transferring between facilities, documentation should include:

• Current medication schedule and dosages
• Recent lab results and diagnostic findings
• Scheduled treatments/appointments
• Contact information for the transferring facility 1

2. Discharge Planning Documentation

• Begin discharge planning at least one month before discharge
• Document applications for appropriate entitlements
• Provide written summary of current health issues
• Include medication list with doses and schedule
• Document follow-up appointments with community providers 1

Documentation for Specific Conditions

1. Pain Assessment and Management

• Use and document results from validated pain assessment tools at least once daily
• Document pain management strategies including both pharmacological and non-pharmacological approaches
• Document additional analgesia needs for procedures 1

2. Specialty-Specific Documentation

For patients with conditions requiring specialist care:

• Document frequency of specialty visits (e.g., daily ophthalmological review for eye involvement)
• Document specific treatments and interventions by specialists
• Include multidisciplinary team assessments 1

Documentation Best Practices

1. Avoid Documentation Pitfalls

• Avoid excessive use of templates, drop-down lists, and check boxes that can standardize away the uniqueness of each patient encounter 1
• Avoid "cloning" documentation (copying previous notes without updating) as this can misrepresent medical necessity 1
• Document synthesis of information over time rather than fragmented data points 1

2. Enhance EHR Documentation Efficiency

• Use hybrid documentation combining narrative elements with context-sensitive, template-driven data 1
• Ensure documentation serves as a dynamic, team-oriented communication tool 1
• Document information in standardized, easily accessible locations within the EHR 3

Common Pitfalls to Avoid

1. Buried Information: Advance care planning documentation is often inaccessible in progress notes rather than in centralized locations, making it difficult to find during emergencies 2, 3

2. Incomplete Allergy Documentation: Drug allergy identification is often missed in minority groups who lack English proficiency (62.5%) compared with white patients (12%) 1

3. Lack of Explanatory Documentation: 50% of patients with completed legal forms/orders have no accompanying documented explanatory discussions 2

4. Excessive Time on Documentation: Physicians spend nearly as much time on documentation (26.6%) as they do on direct patient care (27.5%), which can detract from patient interaction 4

By implementing these documentation practices, healthcare providers can ensure better continuity of care, reduce medical errors, and improve outcomes for patients with complex medical conditions.