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

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.

Principles of Documentation

The four primary topics to be considered are:

• the context of documentation
• the characteristics of effective documentation
• the common elements of documentation
• the methods of documentation

Context of Documentation

Contextual factors related to documentation include:

• different clinical settings (for example, acute in-hospital care vs home visit vs outpatient practice)
• external factors such as different norms, processes and influences. These factors are often outside the control of the rehabilitation professional
• education strategies for documentation
  • 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
  • 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
    • more documentation-related teaching activities in pre-clinical courses are recommended, and clinical placement facilities should provide clear site-specific expectations to students
  • documentation processes may be a valuable learning tool for interprofessional collaboration among students

Relevant components to consider:

• 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
  • accreditation or regulatory bodies
  • researchers
  • patients and clients
    • 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:
      • An Open Discussion of the Impact of OpenNotes on Clinical Ethics: A Justification for Harm-Based Exclusions from Clinical Ethics Documentation
      • Clinical ethics consultation documentation in the era of open notes
  • ourselves
    • remember that personal factors such as state of mind, fatigue, culture and background, cultural perspectives and practices also affect documentation
• the setting in which documentation occurs
• the influence of time on documentation

Characteristics of Effective Documentation

Effective documentation should be:

• comprehensive
• concise
• understandable
• clear
• consistent

Inconsistent documentation may lead to undertreatment, reduced quality of care and adverse patient outcomes.

Effective documentation will include elements such as:

• 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.

Common Elements of Documentation

• Information about the patient's current situation and background
• Patient's input
• Measurable and observable data from the patient encounter
• Professional assessment of findings
• Patient-centred plan of care
• Outcomes of care

Patient Situation and Background

Relevant information to include in documentation:

• 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
  • 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

Measurable and Observable Data

• 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

• SOAP notes
  • Subjective
  • Objective
  • Assessment
  • Plan
  • You can read more here: SOAP Notes

• DAP notes
  • Data
  • Assessment
  • Plan

• PIE notes
  • Problem
  • Intervention
  • Evaluation

• BIRP/ SIRP notes
  • Behaviour / Situation
  • Intervention
  • Response to intervention
  • Plan

• Narrative format
• Problem-Oriented Medical Record (POMR)
• Functional outcomes reporting

Evidence supports the use of standardised frameworks and education strategies to enhance communication and reporting accuracy and reduce error and harm. 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
• Best practices in medical documentation: a curricular module
• Common data elements for meaningful stroke documentation in routine care and clinical research: retrospective data analysis

Methods of Documentation

• Narrative documentation
  • free-writing, long phrases or full sentences, paragraph formation on blank spaces on paper, text boxes, blank computer-based forms, dictation
  • sometimes written chronologically (telling a story)
  • different practice settings will have different structures and flow of documentation
  • may use own or provided templates
  • time-intensive
  • sometimes used when documenting initial patient encounters, interim notes, re-evaluations and discharge summaries
  • disadvantages of narrative documentation include:
    • 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
  • 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.
  • read more about electronic documentation: Electronic Medical Records