What are the best practices for documenting patient information in healthcare settings?

Best Practices for Documenting Patient Information in Healthcare Settings

The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication, with documentation practices focused on clarity, brevity, and attention to the needs of other readers, including patients. 1

Core Documentation Principles

Patient-Centered Documentation

• Include the patient's story in sufficient detail to accurately retell it 1
• Avoid pejorative language in descriptions of patients, behaviors, and findings 1
• Document care plans clearly to support ongoing patient care 1
• Ensure documentation is an accurate but brief synthesis of history, findings, decision making, and plans 1

Structured vs. Narrative Documentation

• Capture structured data only where useful for care delivery or essential for quality assessment/reporting 1
• Preserve the integrity of the patient narrative by minimizing requirements for structured data 1
• Use macros and templates appropriately to improve completeness and efficiency, particularly for standardized elements like review of systems 1
• Avoid excessive use of drop-down lists and check boxes that can disrupt clinical thinking and storytelling 1

Documentation Techniques and Pitfalls

Effective Use of EHR Features

• When using copy/forward functionality, ensure all information remains accurate and relevant 1
• When leveraging templates or previously documented information, avoid creating contradictory information 1
• Indicate the source of data when pulling information from another location in the chart 1
• Avoid "note bloat" where key findings and actions are obscured by superfluous negative findings 1

Common Pitfalls to Avoid

• Documentation cloning that creates redundant, non-updated information 1
• Excessive documentation beyond what is necessary for patient care 1
• Neglecting to document social and emotional health topics, which research shows are documented only 30.6% of the time after discussion 2
• Focusing solely on medical concerns while omitting psychosocial factors that impact health management 2

Integration of Patient-Generated Data

• Properly integrate patient-generated health data while maintaining data source identity 1
• Document the provenance of all data in the clinical record 1
• Include data from patient questionnaires, tracking devices, and patient communications 1
• Ensure physicians and healthcare professionals can trust the data by understanding its source 1

Open Notes and Patient Access

• Patient access to progress notes may improve both patient engagement and quality of care 1
• Consider that patients will be reading notes when documenting, which may lead to:
  • Increased clarity in documentation of care plans
  • More timely completion of notes
  • Avoidance of pejorative language 1
• Patient review provides a new form of peer review that can improve documentation accuracy 1

Implementation and Training

• Provide effective and ongoing EHR documentation training for clinical personnel 1
• Update training with every system upgrade 1
• Develop "chart etiquette" principles and policies based on well-defined standards 1
• Monitor user satisfaction to facilitate successful adoption of electronic documentation systems 3

Documentation for Interdisciplinary Communication

• Ensure documentation supports seamless communication between care team members 1
• Document social and emotional factors that are relevant to health management to support interdisciplinary communication during care transitions 2
• Focus on documenting elements that will improve handoffs between outpatient and inpatient care 2

By following these best practices, healthcare providers can create documentation that effectively supports patient care while meeting regulatory requirements and facilitating communication among the healthcare team.