Clinical Documentation Norms

Clinical documentation is the process by which we record health observations, assessments or plans so that they can be shared with other members of the healthcare team. Clinical documentation serves communication, collaboration and coordination, with norm-dependent effectiveness.

Documentation Types

There are two broad categories of clinical documentation, summative and change (progress).

Summative documentation:

        • Gathers information pertinent to an encounter or episode, organizes observations, exposes meaning and offers a plan keyed to care goals.

        • Examples include consultation notes, admission histories, discharge summaries, surgery reports, transfer notes and integrative plans of care.

Good summative documentation is consistent and comprehensive. It is typically longer than change documentation, as it provides a snapshot of all clinical information pertinent to a particular clinical decision-making task. The task might be broad, such as a periodic health assessment, or relatively narrow, as might occur when answering a specific consultation question or assessing a patient's peri-operative risks.

Change documentation

        • Exposes new findings, describes clinical progress or otherwise indicates what is unique or important about a defined period within a larger encounter, highlighting clinically important developments since the last progress note.

        • Examples include progress notes and other transactional records.

Good change documentation is concise and pertinent. Digital documentation should facilitate brevity, not note-bloat. This is achieved by recognizing that clinical information system (CIS) users have instant access to all test results, measures and other clinical content. If material stored elsewhere in the chart is important to reference, the content can be linked and the meaning summarized. Clinical meaning is better communicated when data is explained rather than duplicated.

Documentation Behaviours

A number of user-controlled documentation behaviours can have a dramatic effect on the clinical, communication and coordination value of clinical documentation. The CIS provides users with powerful tools that can ease and speed documentation. Used indiscriminately, these can degrade the signal-to-noise ratio of a shared health record.

Clinical Copy-Paste

In general, copy-paste is not needed and should not be used. Copy-out (copy from the Connect Care CIS to a separate information system) must be done with extreme caution. Copy-in (copy from one location within the CIS to another location) should be minimized, with the copied information and context attributed.