Required Documentation

While clinicians have the opportunity to record (progress) "Notes" for almost all encounter types, some encounters cannot be closed without at least some form of documentation. This "technical" requirement means that clinicians cannot close the encounter until required notation is signed. 

Other encounters may require one or more types of documentation in order to comply with legislative, organizational, accreditation or other regulations. These "policy" requirements may not be satisfied and yet the associated encounter can still be closed. Accountable clinicians may receive In Basket reminders or alerts (e.g., chart checklists) about missing documentation that is required as a matter of policy.

Inpatient Encounters

All inpatient encounters, where a patient is admitted to and later leaves a healthcare facility, must include both admitting and discharge summative documentation. 

Admission Documentation

An admitting "history and physical" (H&P) document must be filed for all admitted patients. When adding a note to a patient's chart, "H&P" is one of the note types available for selection; it is not possible to sign a new note without a type selection.

The H&P can be as simple as a standardized paragraph containing key information related to, for example, a short-stay surgical encounter. For patients presenting with more complex problems, the H&P provides an invaluable opportunity to validate core structured data in the patient's chart, including home medications, adverse reactions, active health problems and historical medical, surgical, social and family health problems. The H&P also summarizes a patient's health state at a point in time and serves as a key "summative" documentation object in the health record.

Discharge Documentation

Some kind of discharge document must be filed for all admitted patients when leaving a facility without expectation of return. Patients may leave by virtue of being discharged home, transferred to another facility, dying or leaving against medical advice. When adding a note to a patient's chart, "Discharge Summary" should be selected at the note type. Within this document type, templates for "Discharge Summary", "Deceased Note" and "Transfer Note" are appropriate.  It is not possible to sign a new note without a document type selection.

Discharge documentation serves to summarize what happened during an inpatient encounter. It also serves as a key care coordination tool, communicating to other providers in the patient's circle of care to facilitate a shared understanding of remaining active problems, intended home medications and post-discharge expectations, accountabilities and follow-up arrangements. Accordingly, discharge documentation is "summative."

Outpatient Encounters

Although documentation associated with outpatient encounters is not tracked as part of any organizational charting deficiency protocol, generation of an appropriate and timely communication in response to a referral it is a professional expectation (CPSA standard). The expectation is that a consultation letter is prepared and returned to the referring provider after a first assessment and at appropriate intervals thereafter when patients are followed by a consulting specialty. 

The Connect Care expression of this expectation is a "letter" generated through a communications workflow. In most cases, the letter should use one of the letter templates that automatically also copies the communication to Netcare and to copied physician digital health records through eDelivery.