What is health documentation?

Health Documentation Definition

Health documentation is the process of tracking a patient's condition and communicating the author's actions and thoughts to other members of the care team, which has evolved to encompass more than just physician notes and now includes various forms of clinical data collection using electronic health record systems and other technologies. 1

Core Components of Health Documentation

Health documentation serves multiple purposes in modern healthcare:

1. Primary Purpose: To create concise, history-rich notes that reflect information gathered to develop impressions, diagnostic/treatment plans, and follow-up recommendations 1

2. Communication Tool: Documentation serves as a communication medium between:

   • Healthcare providers across the care continuum
   • Current and future care team members
   • Patients and their providers

3. Legal Documentation: Provides evidence of care delivered and clinical decision-making 2

4. Data Source: Supports quality measurement, research, and healthcare system operations

Evolution of Health Documentation

Health documentation has undergone significant transformation:

• Traditional Paper Records: Initially focused on physician notes

• Modern Electronic Health Records (EHRs): Now encompasses comprehensive data including:

  • Clinical notes from multiple providers
  • Diagnostic test results
  • Treatment plans
  • Patient-generated health data
  • Structured and unstructured information 1

• Emerging Technologies: Documentation now extends beyond EHRs to include:

  • Patient portals
  • Connected home monitoring devices
  • Provider and patient-controlled mobile devices
  • Registries and other health information systems 1

Documentation Quality Principles

The American College of Physicians recommends these key principles for high-quality documentation:

1. Patient Story Inclusion: Documentation should include the patient's story in sufficient detail to accurately retell it 1

2. Appropriate Use of Tools: When used properly, macros and templates can improve completeness and efficiency, particularly for standardized documentation 1

3. Thoughtful Review: EHRs should facilitate review of previously documented information to improve completeness and establish context 1

4. Judicious Information Reuse: The "review/edit/attest, then copy/forward" approach can improve accuracy and efficiency when used appropriately, but copying entire notes without editing ("copy/paste") should be avoided 1

5. Clear Source Attribution: When data are pulled from another location in the chart, the source should be clearly indicated 1

Documentation Challenges

Several challenges affect health documentation quality:

• Note Bloat: Defensive documentation practices have led to excessive documentation with superfluous negative findings and irrelevant information, making records difficult to read 1

• Documentation Errors: Recent research shows that nearly half of notes contain information that cannot be verified from patient encounters, and most issues patients initiate in discussions are omitted from notes 3

• Technology Limitations: Current EHR systems may not adequately support clinicians' cognitive processes during documentation 1

• Competing Priorities: Documentation must serve multiple stakeholders beyond direct patient care, including billing, legal, and quality measurement requirements 1

Best Practices for Health Documentation

To improve documentation quality:

• Focus on Clarity and Brevity: Documentation should emphasize clarity, brevity, and attention to the needs of other readers, including patients 1

• Develop "Chart Etiquette": Organizations should establish principles and policies based on well-defined professional standards 1

• Ongoing Training: Effective and ongoing EHR documentation training of clinical personnel should be a continuous process 1

• Patient Involvement: When permitted by regulations, documentation may contain entries by patients as well as other care team members 1

• Structured Data Capture: EHR systems should enable collection of data from multiple sources, including nuanced medical discourse, structured items, and data captured in other systems and devices 1

Health documentation continues to evolve with technology advancements, but its fundamental purpose remains supporting high-quality patient care through accurate and efficient information capture and sharing.