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.

• Sharing

  • The H&P is automatically copied to the patient's family physician, as well as to the provincial electronic health record (Alberta Netcare) and possibly to community electronic medical records (EMRs) serving providers in the patient's circle of care. 

  • H&Ps are not automatically shared with patients through the MyAHS Connect portal, but are easily flagged for sharing by selecting a "Share with patient" button at the top of the note.

• Requirement

  • An inpatient encounter that does not have an H&P document type is considered deficient. 

• Accountability

  • Responsibility for ensuring completion of an H&P rests with the attending clinician at the time of admission. 

• Reminders

  • Completion of an admission H&P is among items in an "Admission checklist", visible in the default (right) sidebar view in all opened inpatient charts.

  • Failure to file or sign an H&P within 24 hours of admission causes a reminder message (with links to facilitate rapid completion or signing) to appear in the In Basket of the attending clinician at the time of admission.

• Fulfillment

  • Direct H&P Fulfillment with Admitting History and Physical Note

    • The straightforward way to satisfy an admitting H&P requirement is to complete an H&P document type. This can be done directly from the "Notes and Reports" section of the inpatient sidebar index.

  • Indirect H&P Fulfillment with Update H&P Note

    • Sometimes the purpose of an H&P is satisfied by a Consult Note or other summative document prepared at the time of, or in support of, the admitting event. A common emergency department workflow involves the emergency clinician requesting a consult from an inpatient admitting service. The Consult Note is required to complete the consult order, and may contain all the information that would normally be entered in an H&P.

    • Although tempting, clinicians should not create an H&P directing readers elsewhere (e.g., "see consult note"). The H&P is still shared with external systems, and notes redirecting to other notes can add clutter and confusion to these external systems.

    • To select a different summative documentation object to serve as the H&P, the correct workflow is to use the "Update H&P" section of the Admission navigator. This satisfies the charting requirement and avoids duplicate or confusing information being shared with external systems.

      • Tip: Designating a Consult or other Document to serve as an Admitting History & Physical

      • Interval H&P notes are pointers to other documents specific to a point in time. Accordingly, they cannot be edited. If a change is needed to the brief content of the Interval H&P reference text, delete the old Interval H&P and create a new note linked to the same source document.

        • Tip: Updating Interval History and Physical Notes

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."

• Sharing

  • As a core "summative" document, the discharge documents are automatically copied to the patient's family physician, as well as to the provincial electronic health record (Alberta Netcare) and possibly to community EMRs serving providers in the patient's circle of care. 

  • Discharge documents are not automatically shared with patients through the MyAHS Connect portal, but are easily flagged for sharing by selecting a "Share with patient" button at the top of the note.

• Requirement

  • A discharged inpatient encounter chart that does not have a discharge document type is considered deficient. 

• Accountability

  • Responsibility for ensuring completion of discharge documentation rests with the attending clinician at the time of discharge, transfer or death. 

• Reminders

  • Completion of a discharge document is among items in an "Discharge checklist" visible in the default (right) sidebar view in all opened inpatient charts.

  • Failure to file or sign a discharge document within 48 hours of discharge, transfer or death causes a reminder message (with links to facilitate rapid completion or signing) to appear in the In Basket of the attending physician at the time of discharge.

• Fulfillment

  • Direct

    • The only way to satisfy discharge documentation requirements is to complete a "Discharge Summary" document type. This can be done directly from the "Notes and Reports" section of the inpatient sidebar index, where there are links that automatically initiate discharge, transfer or deceased documents with provincially standardized sections and formats.

      • "Discharge Summary", "Deceased Note" and "Transfer Note" templates all satisfy discharge documentation requirements.

  • Indirect

    • There is no acceptable way for a discharge document to "refer" to a different document. If discharge documentation has been entered in error to a different document type (e.g., progress note), it is better to copy the content to a proper discharge document and then delete the other document type.

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.