Clinical Documentation Norms
What is it?
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:
Progress documentation records new or changed findings and 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.
Summative documentation gathers information pertinent to an encounter or episode, organizes observations and offers an assessment and plan consistent with patient goals. Examples of summative documents include consultation notes, admission histories, discharge summaries, surgery reports, transfer notes and integrative plans of care.
Best practices vary by category.
Why does it matter?
The Connect Care health record captures massive amounts of information, especially for patients suffering from chronic health problems. Good clinical documentation increases the ‘signal’ to ‘noise’ ratio, decreasing the chance that important information will be missed.
When summative documentation is done well, the patient’s story is preserved. When progress documentation is done well, new developments are easily appreciated. Well-structured notes are easier to find, filter, scan and trend.
When documentation is not done well, the patient’s story is obscured. Indeed, misuse of forms-based documentation, copy-paste and auto-text drives much of the dissatisfaction with digital health records. Incorrect, inefficient or ineffective documentation erodes the credibility and usefulness of the record.
Who is responsible?
All healthcare providers have documentation management responsibilities. These responsibilities may be primary, where the clinician is entirely accountable for what they record. The responsibilities may be secondary, where the prescriber oversees trainees, learners or scribes and approves or revises their documentation. Norms apply whether one is an original author, contributor, editor or approver.
Prescribers are responsible for the content of documentation they sign, irrespective of how it was composed.
How is it done?
Good clinical documentation is concise and unique. A well-organized electronic record promotes brevity because related information can be referenced and linked, not copied. Clinical notes can be interpretive, focusing on the meaning of data found in other sections of the record.
Minimizing inappropriate duplication reduces information burdens for both producers and consumers of notes. Information gathered by any member of the multidisciplinary team can be cross-referenced. Duplicative discipline-based documentation silos are discouraged.
While brevity decreases documentation burdens for both writers and readers, it is important to avoid abbreviations or acronyms that may not be known to all documentation stakeholders.
Progress Documentation
When documenting multiple times during an extended encounter, each “progress” record should emphasize what has changed since the prior note. Efficiency is favoured over comprehensiveness.