Principles of Documentation
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Top Contributors - Wanda van Niekerk and Jess Bell
Introduction to Professional Documentation[edit | edit source]
Principles of Documentation[edit | edit source]
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[edit | edit source]
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.
Related forms such as templates and electronic health records
Components of the context of documentation to consider are:
The audience (readers of documentation)
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.
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.
Characteristics of Effective Documentation
Comprehensive
Concise
Understandable
Clear
Consistent
Include elements such as:
When and where session occurred
Who was present/ notable to the event
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
Accurate
Truthful
Ethical principles
Integrity
Accountability
Independence and impartiality
Respect
Professional commitment
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