Principles of Documentation
Original Editor - Wanda van Niekerk based on the course by Angela Cecil
Top Contributors - Wanda van Niekerk and Jess Bell
Introduction to Professional Documentation[edit | edit source]
Precise clinical documentation is key, as it plays a crucial role in patient care, facilitating communication among various healthcare disciplines and ensuring proper financial reimbursement. Developing and mastering the capability to create high-quality clinical documentation is a fundamental skill that every healthcare professional must acquire.[1]
Principles of Documentation[edit | edit source]
The four primary topics to be considered are[2]:
- the context of documentation
- the characteristics of effective documentation
- the common elements of documentation
- the methods of documentation
Context of Documentation[edit | edit source]
Contextual factors related to documentation include:
- different clinical settings (for example, acute in-hospital care vs home visit vs outpatient practice)[3]
- external factors such as different norms, processes and influences. These factors are often outside the control of the rehabilitation professional[3]
- education strategies for documentation[2]
- nursing: it has been found that education alone may enhance compliance to improve documentation in nurses, but more research is necessary to determine if it will be to a meaningful extent[4]
- physiotherapy: a disconnect between university education providers and clinical placement facilities regarding clinical documentation preparation and training of students has been reported
- all stakeholders should find ways to support students in understanding the importance of clinical documentation and to work on their documentation skills[5]
- more documentation-related teaching activities in pre-clinical courses are recommended, and clinical placement facilities should provide clear site-specific expectations to students[5]
- documentation processes may be a valuable learning tool for interprofessional collaboration among students[6]
Relevant components to consider[2]:
- the audience (readers of documentation)
- colleagues (same profession as well as other members of the multidisciplinary team)
- payers / funders for services such as insurance companies
- utilisation reviewers and auditors
- students[6]
- accreditation or regulatory bodies
- researchers
- patients and clients[7]
- if you would like to read more about the impact of OpenNotes (a mandate in the United States of America, which requires that most health-related documentation be readily available to patients in real-time) on Clinical Ethics, you can read the following articles:
- ourselves
- remember that personal factors such as state of mind, fatigue, culture and background, cultural perspectives and practices also affect documentation[9]
- the setting in which documentation occurs
- the influence of time on documentation[10]
Characteristics of Effective Documentation[edit | edit source]
Effective documentation should be:
- comprehensive
- concise
- understandable
- clear
- consistent
Inconsistent documentation may lead to undertreatment, reduced quality of care and adverse patient outcomes.[11]
Effective documentation will include elements such as[2]:
- when and where the session occurred (date and time)
- who was present/ notable at the event (signed)
- what occurred during the session
- how it occurred
- outcome of the session
- patient and / or caregiver participation and response to the session
- patient condition
- plan of care
- context relevant to the encounter
- common background information – social and surgical history, past medical history, allergies, medication lists, lab and radiology results
Patient-centered ethical documentation is accurate and truthful. Ethical principles to follow include these listed in the World Health Organization's Code of Ethics and Professional Conduct: integrity, accountability, independence and impartiality, respect and professional commitment.[13]
Common Elements of Documentation[edit | edit source]
- Information about the patient's current situation and background[14]
- Patient's input[14]
- Measurable and observable data from the patient encounter[14]
- Professional assessment of findings[14]
- Patient-centred plan of care[14]
- Outcomes of care[14]
Patient Situation and Background[edit | edit source]
Relevant information to include in documentation[2]:
- what brings the patient to you, the rehabilitation professional?
- personal background
- current condition
- past medical history
- medications
- referrals
- information unique to a specific rehabilitation profession
Useful strategies to consider:
- the BLANKETS acronym can help practitioners remember elements of a patient / client's social history[15]
- Bladder and bowel
- Legal arrangements
- Activities of daily living
- Neurology/cognition
- Kit (dentures, hearing / visual aids)
- EtOH (alcohol or smoking)
- Trips/falls (walking aids, exercise tolerance)
- Setup at home
- teach students how to compose the history of present illness (HPI):
- near-peer facilitation may be an effective strategy to teach students how to compose the history of present illness (HPI)
- residents acting as facilitators to second-year medical students were as effective as faculty facilitators in teaching HPI documentation skills[16]
Measurable and Observable Data[edit | edit source]
- Measurements
- Interventions or treatments
- Observations
- Test or assessment results
- Profession-specific interpretation of data - clinical reasoning skills
- Information about patient situation and anticipated implications of presenting issue
Documentation Frameworks[edit | edit source]
- SOAP[17] notes
- Subjective
- Objective
- Assessment
- Plan
- You can read more here: SOAP Notes
- DAP notes[18]
- Data
- Assessment
- Plan
- PIE notes[19]
- Problem
- Intervention
- Evaluation
- BIRP/ SIRP[20] notes
- Behaviour / Situation
- Intervention
- Response to intervention
- Plan
Evidence supports the use of standardised frameworks and education strategies to enhance communication and reporting accuracy and reduce error and harm.[1][22][23] If you'd like to read more about this, please see the following articles:
- Toward a framework for developing an ICF-based documentation system in spinal cord injury-specific rehabilitation based on routine clinical practice: a case study approach[22]
- Best practices in medical documentation: a curricular module[1]
- Common data elements for meaningful stroke documentation in routine care and clinical research: retrospective data analysis[23]
Methods of Documentation[edit | edit source]
- Narrative documentation
- free-writing, long phrases or full sentences, paragraph formation on blank spaces on paper, text boxes, blank computer-based forms, dictation[14]
- sometimes written chronologically (telling a story)
- different practice settings will have different structures and flow of documentation
- may use own or provided templates[14]
- time-intensive
- sometimes used when documenting initial patient encounters, interim notes, re-evaluations and discharge summaries
- disadvantages of narrative documentation include[14]:
- difficult to read due to a lack of structure and variability among healthcare professionals' writing styles
- a person reading the narrative note may find it difficult to find important information about the patient
- may unintentionally leave out relevant or essential details (if it is not documented, it did not happen)
- Electronic documentation[14]
- computer-based documentation
- usually part of a larger electronic medical or health record within a practice setting or health system
- some professions have their own specific and unique form of electronic documentation. Surgeons make use of synoptic operative reporting, and this has been shown to improve the quality of documentation. Documentation is more complete and time efficient when compared to narrative operative reporting.[24]
- read more about electronic documentation: Electronic Medical Records
References[edit | edit source]
- ↑ 1.0 1.1 1.2 McCabe ME, Mink R, Turner DA, Boyer DL, Tcharmtchi MH, Werner J, Schneider J, Armijo-Garcia V, Winkler M, Baker D, Mason KE. Best practices in medical documentation: a curricular module. Academic Pediatrics. 2022 Nov 1;22(8):1271-7.
- ↑ 2.0 2.1 2.2 2.3 2.4 Cecil, A. Principles of Documentation Course. Plus. 2024
- ↑ 3.0 3.1 American Physical Therapy Association (APTA). Setting-Specific Considerations in Documentation. 2018
- ↑ Bunting J, de Klerk M. Strategies to improve compliance with clinical nursing documentation guidelines in the acute hospital setting: A systematic review and analysis. SAGE Open Nursing. 2022 Feb;8:23779608221075165.
- ↑ 5.0 5.1 Field L, Gane E, Forbes R. Clinical documentation during clinical placements: Perspectives of physiotherapy students and clinical educators. Australian Journal of Clinical Education. 2023 May 2;12(1):1-22.
- ↑ 6.0 6.1 Gudmundsen AC, Norbye B, Dahlgren MA, Obstfelder A. Interprofessional student groups using patient documentation to facilitate interprofessional collaboration in clinical practice–A field study. Nurse Education Today. 2020 Dec 1;95:104606.
- ↑ 7.0 7.1 Kaplan H, Guidry-Grimes L, Crutchfield P, Hulkower A, Horner C, Burke JE, Fedson S. An Open Discussion of the Impact of OpenNotes on Clinical Ethics: A Justification for Harm-Based Exclusions from Clinical Ethics Documentation. The Journal of clinical ethics. 2022 Dec 1;33(4):303-13.
- ↑ Childers C, Marron J, Meyer EC, Abel GA. Clinical ethics consultation documentation in the era of open notes. BMC Medical Ethics. 2023 Dec;24(1):1-6.
- ↑ Brooks LA, Manias E, Bloomer MJ. A retrospective descriptive study of medical record documentation of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds. Australian Critical Care. 2023 Jun 18.
- ↑ Moy AJ, Schwartz JM, Chen R, Sadri S, Lucas E, Cato KD, Rossetti SC. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Journal of the American Medical Informatics Association. 2021 May 1;28(5):998-1008.
- ↑ Tate K, Ma R, Reid RC, McLane P, Waywitka J, Cummings GE, Cummings GG. A first look at consistency of documentation across care settings during emergency transitions of long-term care residents. BMC geriatrics. 2023 Jan 11;23(1):17.
- ↑ MOS Medical Record Reviews. The 5 Cs In Medical Record Documentation. Available from: https://www.youtube.com/watch?v=4PyPFE5yBUc[last accessed 5/2/2024]
- ↑ World Health Organization (WHO). Code of Ethics and Professional Conduct (Abridged). Last accessed 5 February 2024.
- ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 14.11 14.12 Erickson ML, Utzman RR, McKnight R. Physical Therapy Documentation: From Examination to Outcome. Third Edition. SLACK Incorporated. 2020
- ↑ Warner BE, Millar K, Bolland M, McNicholas J, Dani M. BLANKETS: a toasty tool to improve social history documentation for our older patients. Postgraduate medical journal. 2022 Jul;98(1161):564-6.
- ↑ Kusnoor AV, Balchandani R, Pillow MT, Sherman S, Ismail N. Near-peers effectively teach clinical documentation skills to early medical students. BMC Medical Education. 2022 Dec;22(1):1-4.
- ↑ Gateley CA, Borcherding S. Documentation manual for occupational therapy: Writing SOAP notes. Fourth edition. Thorofare, NJ: Slack; 2017.
- ↑ Reiter MD, Sabo K. Writing Progress Notes. A Therapist’s Guide to Writing in Psychotherapy: Assessment, Documentation, and Intervention. 2023 Jun 28.
- ↑ Almasi S, Cheraghi F, Dehghani M, Ehsani S, Khalili A, Alimohammadi N. Effects of Problem, Intervention, Evaluation (PIE) Training on the Quality of Nursing Documentation Among Students of Hamadan University of Medical Sciences, Hamadan, Iran.
- ↑ OWENS E. Record Keeping and Documentation. In Clinical Mental Health Counseling: Practicing in Integrated Systems of Care. 2019 Sep 9:141.
- ↑ Dkcalgary. How to Write Clinical Patient Notes: The Basics. Available from: https://www.youtube.com/watch?v=GxumhC3C1ss [last accessed 5/2/2024]
- ↑ 22.0 22.1 Pongpipatpaiboon K, Selb M, Kovindha A, Prodinger B. Toward a framework for developing an ICF-based documentation system in spinal cord injury-specific rehabilitation based on routine clinical practice: a case study approach. Spinal cord series and cases. 2020 May 5;6(1):33.
- ↑ 23.0 23.1 Berenspöhler S, Minnerup J, Dugas M, Varghese J. Common Data Elements for Meaningful Stroke Documentation in Routine Care and Clinical Research: Retrospective Data Analysis. JMIR Medical Informatics. 2021 Oct 12;9(10):e27396.
- ↑ Stogryn S, Hardy KM, Abou-Setta AM, Clouston KM, Metcalfe J, Vergis AS. Advancement in the quality of operative documentation: a systematic review and meta-analysis of synoptic versus narrative operative reporting. The American Journal of Surgery. 2019 Sep 1;218(3):624-30.
