A complete cheat sheet for clinical documentation

What is clinical documentation in healthcare?

Clinical documentation refers to the creation of medical records that pertain to patient healthcare. These documents may contain information concerning symptoms, diagnosis, assessment, treatment, as well as any testing. While there is no straightforward or universal standard when it comes to clinical documents, they are used by over 90% of health practitioners in the US and provide relevant insight concerning the patient's health experience. Additionally, clinical documents serve as excellent points of reference to improve your future treatments, as well as rewarding summaries for other healthcare professionals to refer to. Because of their accessible format, they can be easily understood by most health users, and with one glance, practitioners can have an insight into patient treatment. In the case of a lawsuit, clinical documents also serve as sufficient medical reasoning and credit your practice with authority and reputation. 

Fundamental reasons for good clinical documentation

Clinical documentation is essential for a multitude of reasons, and as the healthcare industry is constantly changing and adapting, it is critical that your practice makes efforts to produce high-quality documentation. It ensures patient data is up-to-date, and that all relevant information is stored for reference and future contribution to effective treatments. There are numerous advantages that will result from improving your clinical documentation, including:

Good communication - Documentation outlines all points of interaction between practitioners and patients, and with their concise format, all healthcare professionals should be able to understand a patient’s health state. Clinicians should be able to easily pick up on a client’s health condition from the information listed on the document.

Ensures reimbursement - Good clinical documentation is the key to appropriate medical billing and coding processes. You can ensure that the relevant medical equipment and services are billed and coded for, and as a result, your insurance claims are accurate and more likely to be accepted.

Reduces malpractice - Clinical documentation ensures that you are HIPAA compliant and have medical reasoning behind all your treatment decisions. For example, documents can support you against any claims or potential lawsuits. 

How can private practitioners improve their clinical documentation skills

While every practitioner will have their own methods for writing documentation, here are some valuable strategies to help you improve yours:

Standardize your notes: There are certain guidelines relevant to the industry you work in that are applicable to clinical documentation. By sticking to these standards, you will not only save time in the creation of your documentation, but you will also ensure your notes are organized and easy to read.

Take inspiration from others: Within your field, there will be numerous practitioners who are known for their fantastic documentation. Have a look at the way they take their notes, and don’t be afraid to ask for advice. 

Feedback: One of the best ways to improve any skill is to ask for feedback. If your documentation needs to be shared with other practitioners, ask them how they found your notes. Were they readable? Easily navigated? Organized? 

Keep learning: It’s important to remember that no matter how good your documentation is, it can always be improved. Implementing regular documentation training programs into your practice is a fantastic way to ensure no one gets complacent and new skills are continually taught. 

The basics of clinical documentation

Despite every healthcare practice conducting clinical documents differently, there is a basic structure that you should adhere to, in order to receive the highest level of care for your patients. You should be incorporating the following features to elevate the quality of your notes:

1. Include date and times - In order to properly piece together information, it is important that you document the time and date on each patient note. 
2. Write signatures - You need to sign each page of client information, as well as write your name and role on any documented interaction. This ensures individuals know who is attending to certain patients, and in the case of legal issues, who is responsible. 
3. Make timely entries - Make sure that you compose entries in a timely manner, so you can avoid missing out on critical information. It is equally important to not write them during your sessions, as this can interfere with your client and be perceived as rude.
4. Be legible - Because other healthcare professionals are reading through your documents, they should be typed electronically in order to avoid miscommunication. If they are handwritten, extra care needs to be taken to ensure they are legible and clear. 
5. Avoid abbreviations - Unless they are universal, it is best to avoid abbreviations so you can minimize the risk of misconstrued information. 

Essential elements of good clinical documentation

Regardless of the field of healthcare that you work in, there are some essential components to all clinical documentation. These include the following:

1. Correct credentials: All clinical documentation needs to include the correct credentials of the relevant provider. Clinical notes also need to have the name of the patient that they are referring to and should be stored within this patient’s files.
2. Diagnostic statement: Clinical documentation should include a statement regarding the patient’s current and past diagnosis where necessary. This type of statement should also cover how the patient was diagnosed, the impact of the diagnosis, and any relevant progression that has been clinically observed.
3. Diagnostic methodology: The methodology that has contributed to the diagnosis is very important. The provider needs to explain the tests, assessments, evaluations, observations, and diagnostic criteria that have been applied. If the assessments that have been used are non-formal, it is essential that the provider explains why these were used. 
4. Medications: Documentation should also refer to any current and past medications that the patient has been prescribed.

Tips for effective clinical documentation

To really hone in on what makes clinical documentation effective, there are numerous strategies you should implement to elevate the quality of your service. Doing so will increase patient satisfaction and improve the daily operations of your practice

1. Report critical values - Remember to always report critical values to a nurse within 15 minutes of the data being verified by the lab. Failure to do so can delay treatment, which is detrimental to the patient. They should also be reported to physicians within 30 minutes.
2. Avoid general information and statements - Each clinical document needs to be specific to the patient, and any general statements can easily be misconstrued. For example, simply stating that the patient called is inadequate, and you need to specify whether the patient needs a return call, or if they have a concern or query.
3. Accommodate your busy times - Even in your busiest time of day, you need to be aware of critical codes and transfers, changes of shifts, and different medication and physician orders. Despite how large your load is, you should not miss these vital details. 
4. Correct documentation methods - Your documents should be highly accurate of the patient experience and composed in a legible format so any healthcare professional can pick them up and understand the patient’s condition. They should also contain the subjective perspective of patient symptoms, as well as objective observations. All notes should be in a professional manner using correct spelling, grammar, and tone, and without any personal judgment.
5. Correct notes - Any allergies or medications should be listed, as well as late entries and corrections. 
6. Efficient charting procedures - No charting should ever be completed in advance, and these will be reviewed in addition to flow sheets. Patient assessment must be carefully documented, and with the right nursing policies consulted, these should elevate the quality of your notes. 

5 examples of good clinical documents

To help you visualize what a good clinical document looks like, we’ve included an example of a progress note, separated into five sections. This template is based on a SOAP format, which can be used to standardize and organize your notes. 

Demographic information:

Date of Session: 12/07/2022

Session Duration: 50 minutes

Patient Name: Jane Smith 

Patient Number: XXXXXX

Subjective:

Miss Smith reports continued feelings of depression. She describes her symptoms as having worsened, saying “I find it hard to get out of bed every day”. She is disinterested in her work and no longer enjoys her hobbies, saying she “doesn’t see the point”. Miss Smith also reports feeling symptoms of anxiety and struggles to socialize with friends and family. 

Objective:

Miss Smith had slow verbal responses during the session. She found it difficult to maintain a conversation and her speech had a flat affect. Her compliance with medication is good, but there are no evident improvements. Eating patterns are irregular but weight remains unchanged. She reported having difficulty falling and staying asleep. 

Assessment:

Miss Smith presents as unfocused and disinterested. Her participation was reduced since her last session, and she struggled to maintain conversation and appropriately respond to questions and prompts. Although Miss Smith is compliant with medication, it has not had an observable effect. Suicidal ideas or intentions were not expressed and do not appear present. 

Plan:

Miss Smith is undergoing CBT to alleviate depressive symptoms. Medication will remain unchanged for the next 14 days. If no progress is observed, Miss Smith will be referred to a psychiatrist. Miss Smith will continue to attend weekly therapy sessions. She has been instructed to practice replacing negative self-talk with positive self-talk and has set a goal to go for two walks in between sessions. 

The above examples should illustrate the type of information to include in your documentation and how this can be formatted. Every provider has their own preference for how they write their documentation and whilst this is perfectly fine, you need to ensure all of the right information has been included. 

Further reading:

• The digital hospital of the 21th century, and information systems management
• The Importance and Use of Electronic Health Records in Clinical Research