What is health documentation?

Health Documentation: Definition, Purpose, and Best Practices

Health documentation is a systematic recording of a patient's condition and care that serves to track patient health status, communicate clinical thinking among care team members, and support continuity of care while meeting regulatory, billing, and legal requirements. 1

Core Purposes of Health Documentation

Health documentation was originally developed to:

• Track a patient's condition over time
• Communicate the clinician's actions and thoughts to other care team members
• Support continuity of care across different settings and providers

However, over time, its purposes have expanded significantly to include:

• Justification for billing and reimbursement
• Legal protection (defensive medicine)
• Quality measurement and reporting
• Research and population health management
• Patient engagement and education

Evolution of Health Documentation

Health documentation has evolved considerably over the decades:

• Traditional paper records focused primarily on clinical care
• Problem-oriented medical records (POMR) improved organization around patient problems
• Electronic Health Records (EHRs) have transformed documentation practices, offering both benefits and challenges

The definition of clinical documentation has expanded beyond physician notes to include:

• Data from multiple care team members
• Patient-generated health data
• Information from connected devices and monitoring systems
• Structured data elements for quality reporting and research 1

Best Practices for Health Documentation

According to the American College of Physicians guidelines 1, high-quality health documentation should:

1. Include the patient's story in appropriate detail

   • Capture the narrative elements that provide context
   • Include entries from patients and other care team members when appropriate

2. Use technology appropriately

   • Employ macros and templates judiciously to improve completeness and efficiency
   • Avoid excessive "copy/paste" practices that lead to note bloat and errors
   • Ensure data pulled from elsewhere in the chart is clearly sourced and verified

3. Facilitate thoughtful review of previous information

   • Support "write once, reuse many times" philosophy
   • Tag information to identify original sources
   • Allow for easy search and retrieval of prior relevant data

4. Maintain accuracy and clarity

   • Focus on concise, history-rich notes that reflect gathered information
   • Develop clear impression, diagnostic/treatment plans, and follow-up recommendations
   • Avoid redundant documentation requirements

Common Pitfalls in Health Documentation

Several challenges affect the quality of health documentation:

• Note bloat: Excessive documentation with superfluous negative findings and irrelevant information making it difficult to identify key clinical information 1

• Copy/paste errors: Propagation of outdated or incorrect information through improper use of copy/paste functionality 1

• Missing patient-initiated concerns: Recent research shows most issues that patients initiate in discussions are often omitted from documentation 2

• Verification gaps: Nearly half of notes contain information that cannot be verified from the actual clinical encounter 2

• Time burden: Documentation now occupies 25-50% of clinicians' time, potentially detracting from direct patient care 3

Future Directions for Health Documentation

The American College of Physicians recommends several approaches to improve health documentation:

• Development of professional standards for documentation unique to individual specialties
• Integration of patient-generated data with clear source identification
• Reduction of redundant documentation requirements
• Improved EHR training for clinical personnel
• Focus on the primary purpose of documentation: supporting patient care 1

As healthcare continues to evolve, health documentation systems will likely integrate with or potentially be replaced by newer technologies such as registries, portals, connected home monitoring devices, and mobile applications 1.