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

Dos and Don'ts of Health Documentation

The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication, with concise, history-rich notes that reflect information gathered to develop impressions, treatment plans, and follow-up recommendations. 1

Key Documentation Principles

DO:

• Include the patient's story in sufficient detail to retell it accurately

  • Document the narrative that captures the patient's experience and concerns
  • When permitted by regulations, include entries from patients and other care team members 1

• Use appropriate documentation tools effectively

  • Employ macros and templates appropriately to improve completeness and efficiency, particularly for standardized elements like review of systems and physical examination findings 1
  • When reviewing prior documentation, use "review/edit and/or attest, then copy/forward" selectively for information that remains accurate 1

• Ensure data source transparency

  • When data are pulled from another location in the chart, indicate the source
  • Supplement with appropriate narrative content
  • Make referenced data traceable to its origin 1

• Maintain clarity and brevity

  • Focus on creating concise notes that highlight key findings and actions
  • Avoid "note bloat" where important information gets buried in excessive documentation 1
  • Prioritize clear communication over excessive documentation 1

• Document with multiple audiences in mind

  • Consider that records may be viewed by colleagues, patients, payers, and potentially legal entities 2
  • Avoid pejorative language in descriptions of patients and their behaviors 1
  • Ensure timely completion of notes 1

DON'T:

• Avoid copying and pasting entire notes

  • This practice is inherently risky and should be avoided
  • Copying without proper editing can propagate factual errors, outdated information, and incorrect values 1

• Don't create contradictory information

  • When using templates or previously documented information, ensure it doesn't create inconsistencies 1
  • Review documentation for internal contradictions before finalizing

• Avoid excessive documentation beyond what is necessary

  • While defensive documentation has become common, it can make records difficult to read and obscure key findings 1
  • Focus on quality over quantity

• Don't omit patient-initiated concerns

  • Research shows most issues that patients initiate in discussions are often omitted from notes 3
  • Ensure documentation captures patient concerns, not just clinician observations

• Avoid undocumented observations

  • Nearly half of notes contain information or observations that cannot be verified 3
  • Document only what was actually observed or discussed

Documentation Quality Considerations

Essential Elements to Include

• Complete medication lists (documented in 91.6% of internist records) 4
• Immunization records (documented in 96.2-100% of records) 4
• Screening compliance (documented in 88-90.8% of records) 4
• Drug allergies (documented in only 50.4-61.6% of records) 4
• Smoking history (documented in only 20.4-37.8% of records) 4
• Assessment and plan for each encounter 3
• Follow-up information including when patients should return 3

Documentation Improvement Strategies

1. Develop standardized documentation practices

   • Create "chart etiquette" principles based on well-defined standards 1
   • Identify commonly underdocumented or incorrectly documented clinical conditions 5

2. Establish clear definitions

   • Develop definitions for commonly documented conditions 5
   • Ensure consistent understanding among clinicians

3. Provide education and training

   • Have medical directors educate clinicians on proper documentation 5
   • Focus on areas with known documentation gaps

4. Measure and manage documentation performance

   • Regularly assess documentation quality 5
   • Provide feedback to improve documentation practices

Common Pitfalls and How to Avoid Them

• Documentation bloat: Focus on concise, relevant information rather than excessive documentation to satisfy coding requirements 1

• Overreliance on templates: While templates improve efficiency, they can lead to generic documentation that doesn't accurately reflect the specific patient encounter 1

• Missing follow-up information: Always include clear instructions about when patients should return and what follow-up is needed 3

• Inconsistent documentation: Establish standardized approaches to documentation within practices to ensure consistency 1

• Failure to document patient-initiated concerns: Make a deliberate effort to document issues raised by patients, not just clinician observations 3

By following these guidelines, clinicians can create documentation that effectively supports patient care while meeting regulatory and legal requirements, ultimately improving clinical outcomes through enhanced communication.