Clinical Documentation

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. All forms of clinical documentation serve communication, collaboration and coordination.

There are two categories of clinical documentation:

    • Summative documentation gathers all information pertinent to an encounter or episode, organizes observations, exposes meaning, and offers a plan keyed to care goals. Examples of summative documents include consultation notes, admission histories, discharge summaries, surgery reports, transfer notes and integrative plans of care.

    • Progress documentation records new or changed findings, clinical progress or otherwise indicates what is unique or important about a defined period within a larger care encounter or episode. Progress notes are typical transactional documents. Ideally, they highlight clinically important developments since the last summative note.

Change Documentation

Good clinical documentation is concise and pertinent. Digital documentation should facilitate brevity, not note-bloat. This is acheived by recognizing that 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 explained rather than duplicated.

Clinical Copy-Paste

In general, copy-paste is not needed and should not be used. Copy-out (copy from 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.