What should be included in health documentation for patients?

Essential Components of Health Documentation for Patients

Health documentation should primarily serve to support patient care and improve clinical outcomes through enhanced communication, with concise, history-rich notes that reflect gathered information used to develop impressions, treatment plans, and follow-up recommendations. 1

Core Documentation Requirements

The American College of Physicians (ACP) provides clear guidance on what should be included in health documentation for patients:

Patient Story and Narrative

• The clinical record must include the patient's story in sufficient detail to retell it accurately 1
• Documentation should preserve narrative elements that support ongoing patient-physician relationships
• When permitted by regulations, documentation may contain entries by the patient and other care team members 1

Clinical Information Components

• Problem-oriented documentation that focuses on problems and their management 1
• Chronic conditions management (documented 87.5-91.7% of the time after discussion) 2
• Acute/new problems assessment and plans (documented 87.5-91.7% of the time) 2
• Disease prevention measures and recommendations (documented 87.5-91.7% of the time) 2
• Social and emotional health factors (currently documented only 30.6% of the time despite their importance) 2

Medication and Allergy Documentation

• Accurate allergy documentation in coded, non-free-text format to trigger clinical decision support and prevent adverse events 3
  • Avoid free-text allergy entries which bypass safety alerts 4, 3
  • Document specific reaction types, not just the allergen 3
  • Distinguish between true allergies and adverse effects 4
• Medication details including dosage, timing, and administration routes 5
  • For medications like insulin, document specific instructions for administration 5

Documentation Best Practices

Use of EHR Tools

• Appropriate use of templates and macros to improve completeness and efficiency, particularly for standardized elements like review of systems 1
• When using copy/forward functionality:
  • Review, edit, and attest to information accuracy 1
  • Avoid copying entire notes without careful editing 1
  • Ensure source of data is indicated when pulled from another location 1

Quality Considerations

• Clarity and brevity should be prioritized over excessive documentation 1
• Documentation should be concise while containing sufficient detail to support clinical reasoning 1
• Avoid "note bloat" where key findings are obscured by superfluous negative findings 1

Interdisciplinary Communication

• Documentation should facilitate communication between care team members 1
• Include information needed during care transitions and handoffs 2
• Document social and emotional factors that may impact treatment decisions and outcomes 2

Common Pitfalls to Avoid

1. Excessive copy/paste that propagates errors through multiple notes 1
2. Inadequate documentation of social/emotional factors which are documented only 30.6% of the time after discussion 2
3. Free-text allergy entries that bypass clinical decision support systems 4, 3
4. Documentation primarily for billing/coding rather than patient care 1
5. Overstructuring the clinical record with extraneous data that diminishes the narrative value 1

Documentation Training

Effective and ongoing EHR documentation training should be provided to all clinical personnel as an ongoing process 1. This should include:

• Professional standards for high-quality documentation
• Appropriate use of EHR tools and features
• Balance between structured data and narrative elements
• Proper documentation of allergies and medications

By following these guidelines, health documentation can fulfill its primary purpose of supporting patient care while meeting secondary needs for billing, quality measurement, and regulatory compliance.