Last updated: July 30, 2021
Fundamentals of Medical Documentation
Fundamentals of Medical Documentation
Medical documentation records the findings, observations, and facts about a person’s health history, including present and past diseases, tests, treatments, and outcomes. Proper and adequate medical documentation ensures the quality of health and medical care services across the industry. This article will lay out some basic principles of proper documentation and how those features promote risk management and liability prevention.
Purposes of documentation
While medical documentation acts as an important communication tool, it is crucial to ensure the safety of the patient. It reduces the risk of medical errors and encourages positive outcomes.
Collaboration: Complete and accurate medical documentation improves the quality of care by giving the team the information to provide the patient with the right care at the right time.
Communication: Medical documentation is a way to inform other healthcare providers about the treatment plans of your patient, which increases the quality of patient care and reduces the chances of any malpractice.
Treatment: A patient’s medical record states the problem in the patient’s words, then describes the plan for the treatment. It also states how effective the treatment was for the patient, which creates a permanent record for future care.
Data collection: A complete record creates a database to study how effective a treatment is for a particular disease, and can be used for research purposes.
Basic principles of documentation
Documentation does not require comprehensive details, rather it has to be precise yet complete and legible. This approach increases efficiency, reducing the time spent on this process by following the three chief principles of documentation stated below:
1. Risk-benefit analysis
First, the important decisions and risks and benefits must be recorded while the patient is being provided with clinical care. This risk-benefit analysis must include the obvious benefits of a taken decision. The clinicians mostly focus on the possible risks side of the decision while paying less attention to the benefits. For instance, the decision of providing a certain medication to a patient has both risks and benefits, so both should be cited (i.e., side effects or allergies it can cause along with the risks if the medicine is not provided).
If the patient suffers from an ill-effect of the medication provided, the plaintiff’s attorney can easily frame the clinician for providing a harmful drug to the patient. However, that won’t be the case if the clinician has noted the medication’s benefits, the risks if the medication was not provided, and counseling of the potential negative side effects of the medicine.
2. Clinical Judgment
It is essential to use clinical judgment (i.e., assessment of a clinical situation and a corresponding response to that assessment) at crucial decision points. Clinical judgment helps in liability prevention and helps avoid negligence (i.e., the primary cause of malpractice). It is a thoughtful process in which healthcare providers come up with a conclusion based upon the subjective and objective analysis of the patient.
The clinical judgment and the response have to be congruent. For instance, “The patient no longer shows any symptoms of the disease. Discharge today.” This is a congruent response to an assessment.
3. Patient’s ability of self-care
The last principle refers to stating the ability of the patient to play a part in their own care. This ability includes:
- Awareness of the symptoms that indicate worsening of their condition
- Understanding the purposes of the prescribed medications
- Ability to sense the emergency
If the patient is not capable of doing so then this information must be provided to someone else, to the family, or a guardian.
Following these three principles delivers concisedocumentation that reduces the burden of record-keeping. These tips successfully achieve the aim of addressing critical risk management factors.
Other things that must be legibly included in medical documentation are:
- The reason for the patient encounter
- Relevant history of the patient
- Any prior diagnostic test results
- Findings of physical examination
- The plan for further care
- Date and the identity of the patient
“Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings” by CDC Global Health is licensed under CC BY 2.0
Documentation pitfalls to avoid
It is considered critical that a person should never try to change the existing record. Nothing should be added that would harm the transparency of the documentation. If something needs to be added, it should be distinctly marked so that the reader knows what was original text and what the new amendments or additions are.
Secondly, while writing medical documentation professional tone must be maintained. A casual, sarcastic, or demeaning tone can reflect badly on the healthcare provider.
Careful documentation protects the clinicians from legal jeopardy. However, this is only one of the many reasons to write and record medical documentation. Medical documentation helps to increase the quality of patient care. It is an effective way to communicate the patient’s history, assessment details, and treatment plan among healthcare providers. It has to be concise, yet complete and this motive can be achieved by following the basic principles of documentation stated above.