Principles of Documentation

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Principles of Documentation

The four primary topics to be considered are:

• Context of documentation
• Characteristics of effective documentation
• Common elements of documentation
• 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. ref - APTA Setting specific considerations in documentation
• education strategies for documentation
  • studies in nursing have shown 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. 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.
  • A disconnect between university education providers and clinical placement facilities are reported regarding the clinical documentation preparation and training of physiotherapy students. 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. 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.
  • Documentation processes may be a valuable learning tool for interprofessional collaboration among students.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.

Components of the context of documentation to consider are:

• The audience (readers of documentation)
  • colleagues (same profession as well as other members of multidisciplinary team)
  • payers for services such as insurance companies
  • utilisation reviewers and auditors
  • students 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.
  • accreditation or regulatory bodies
  • researchers
  • patients and clients
    • If you'd like to read more about the impact of OpenNotes on Clinical Ethics, please read this article: 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.
  • ourselves
    • Remember that personal factors such as state of mind, fatigue, cultures and backgrounds, cultural perspectives and practices also affect documentation. 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.
• Setting in which documentation occurs
• Influence of time surrounding documentation 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.

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.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.

Include elements such as:

• When and where session occurred (date and time)
• Who was present/ notable to 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 encounter
• Common background information – social and surgical history, past medical history, allergies, medication lists, lab and radiology results

Patient-centered ethical documentation is:

• Accurate
• Truthful

Ethical principles to follow:

• Integrity WHO
• Accountability WHO
• Independence and impartiality WHO
• Respect WHO
• Professional commitment WHO

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

Strategies to use:

to remember elements of a patient/client's social history BLANKETS 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.

• 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

Near-peer 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.

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