Standardized Documentation Templates
While the Connect Care clinical information system offers wide content and formatting freedom to the authors of clinical documentation, readers request consistency in both content and formatting in order to ease the use of documentation for clinical work. It is especially important that summative documentation adhere to some rudimentary style and content standards, as the users of care transition documentation often work in different contexts with different documentation habits.
Alberta Health Services has collaborated with a broad range of documentation stakeholders -- including diverse clinicians, professional associations, regulatory bodies, information management experts and documentation improvement initiatives -- to develop provincial summative documentation standards. These recognize that diverse care contexts may have particular documentation needs. However, there are core elements (sections) that all summative documentation should contain. And those should be ordered and labelled in consistent and easily recognizable ways. In addition, the consumers of summative documentation strongly advocate for action-oriented summative documents that emphasize clear assessment and plan statements combined with explicit accountability indications. It is especially important for community physicians to know what is expected of them in the ongoing management of patients' problems.
Provincially Standardized Documentation Templates
Standardized templates have been developed for both change and summative documentation. These take the form of SmartText and/or SmartPhrases and are made available through point-and-click links (so that the user does not need to know template names) in chart sidebars.
The layout and headings recommended for change (progress) documentation are offered in the spirit of bringing more consistency and quality to chart sections that clinicians rely upon to appreciate how a patient is progressing on a particular clinical journey. Progress notes prepared as part of problem-oriented charting are expected to follow standards for content (e.g., documentation by exception), headings and layout.
There are greater expectations for standards compliance in the case of summative documentation, especially for the summative documentation note types that are automatically shared with external clinical information systems. These include admission history & physical notes, consult notes, discharge summaries, deceased summaries, inter-facility transfer summaries, operative reports, obstetrical summaries and emergency provider notes.
Standardized properties of shared documents include:
Header blocks - with consistent patient, provider and context identification information that is always found in the same (relative) place.
Sections and Labels - with expected content (e.g., summary of hospital course in discharge, deceased and transfer summaries) identified by consistent sub-headings
Layout - with the minimum expected sections consistently ordered to facilitate recognition and scanning for information sought by note readers.
All Connect Care users should prepare summative documents that comply with minimum content, format and layout expectations. Specialty and context-specific adaptations are welcome. These usually relate to the content mandated sections. In addition, some contexts may need additional sections, ideally nested within standardized major sections.
The documentation style expressed in provincially standardized templates (e.g., font size and weight for headings and subheadings, use of indentation, etc.) should be followed within any specialty adaptations.
Specialty groups can request provincially endorsed variants of the major summative templates and have these automatically substituted by Connect Care when a document type is selected for note preparation.
Provincially standardized templates are provided in three variants, reflecting different levels of interactivity and integration.
The most basic template format emphasizes minimum expectations for the layout and sections of compliant documentation. A header section contains required identifiers and descriptors laid out in a way that works well for both Connect Care and external information systems. The remainder of the template provides expected major sections, with standardized labels, in the expected order and style.
Headings Only templates can work well for clinicians who prefer to dictate the majority of a summative document. Little to no chart content is automatically pulled into the note. Headings Only templates are also good to use as a starting point for speciality or contextual customizations or personalizations. The header, sections and font styles should be preserved.
Basic templates contain all the content and formatting of Headings Only templates. In addition, they pull in commonly used chart elements (e.g., problem lists, medication lists, etc.) in expected locations.
Basic templates also work well for dictation. However, they are more efficient in that the user is spared the work of re-entering common data from the patient's chart.
Advanced templates have all features of Basic templates. In addition, they pull in all relevant patient chart content.
Advanced templates minimize the amount of information that a clinician may need to dictate, or otherwise enter, into a note. However, they do expect that users have been maintaining chart structured data. This includes basic content, like problem lists, but also includes more advanced charting tools, like hospital course summaries and problem-oriented assessments and plans.