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:

  1. 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.

  2. Summative documentation gathers all information pertinent to an encounter or episode, organizes observations, exposes meaning, and offers a plan keyed to 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.

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.

Summative Documentation

Summative documentation serves consultations, admissions or transitions with a note that can stand on its own. Comprehensiveness is favoured over efficiency.

Summative documentation may gather material from multiple parts of the chart. Accordingly, summative notes are more likely to benefit from text automations that pull information, such as problems, allergies, medications and investigations, into the note to reflect the state of that data at the point of analysis.

Summative documentation can be gradually built as the patient’s journey unfolds, as happens when the "hospital course" tool is used. Ideally, the only work remaining at care transitions is to reconcile problems and medications while confirming care plans and follow-up accountabilities.

The layout and content of summative documentation should be standardized whenever possible, adhering to Alberta provincial expectations by using provided Connect Care basic or problem-oriented charting templates. Discharge Summaries, for example, need to have consistent sections in a consistent order. This facilitates communication with clinicians who work where Connect Care is not the record of care.

How is compliance measured?

Feedback about adherence to clinical documentation minimum use norms is provided to prescribers using In Basket charting deficiency messages. These focus on whether required summative documentation has been completed within expected time frames for inpatient encounters. Currently, qualitative measures that might reflect the usefulness of clinical documentation, or compliance with specific norms (e.g., Copy-Paste), are provided in anonymized form to appropriate Connect Care and clinical leadership groups. Individuals

Inpatient Summative Documentation Compliance

AHS medical staff bylaws stipulate that responsible prescribers must complete and sign the following required summative documentation types for all inpatient encounters:

  • Admitting History & Physicals (or "Update H&P" note pointing to an equivalent document)

  • Operative Reports

  • Discharge Summaries

  • Emergency Department Provider Notes

In Basket messages are sent to responsible prescribers for each of the above summative documents. Messages relating to H&P and operative note deficiencies are posted within 24 hours, whereas messages relating to discharge summaries and ED provider note deficiencies are highlighted at 14 days post discharge.

Overdue deficiencies are subject to reporting to Medical Affairs once 10 deficiencies reach 29 days overdue or 4 deficiencies reach 90 days overdue. Notifications of overdue deficiencies and possible privilege curtailments are addressed by each zone’s Medical Affairs office.

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