As a healthcare professional, accurate and thorough documentation is absolutely vital. Your notes and records don’t just help provide consistent, quality care, they’re also legal documents that can be called upon in court cases. Sloppy, incomplete, or hard-to-read documentation puts patients at risk and opens you up to liability. This is why developing good documentation habits is so important.
The Basics of Medical Documentation
At its core, medical documentation just means keeping a detailed written account of a patient’s symptoms, medical history, test results, diagnoses, treatments, and advice given. This creates a paper trail that allows different providers to all stay on the same page about that patient’s care.
Your documentation should be:
- Factual and objective, not emotional or speculative.
- Timely – write it down as soon as possible.
- Clear and legible, without abbreviations that could be misunderstood.
Using Standardized Terminology
According to the people over at Med Abbrev, to ensure consistency, most healthcare facilities use standardized terminology and abbreviations developed by organizations like the Joint Commission. For example, ‘SOB’ is a common medical abbreviation meaning ‘shortness of breath’.
Using unique slang or shorthand can lead to dangerous miscommunications. Always be crystal clear in your documentation.
Proper Documentation Format
Most facilities will have their own approved format and forms for documentation. In general, a SOAP note is the standard, covering:
- Subjective: The patient’s reported symptoms/complaints.
- Objective: Observable evidence like vitals, test results.
- Assessment: The provider’s evaluation and diagnosis.
- Plan: Recommended treatment, medications, tests, etc.
Maintaining Privacy and Security
Healthcare documentation contains extremely sensitive personal information, so protecting patient privacy is paramount. Never leave paperwork or computer terminals unattended where data could be exposed.
Only share the minimum information necessary when coordinating care with other providers. Ensure all documentation is properly stored and disposed of following HIPAA regulations.
The Importance of Accurate Details
Vague documentation that lacks specific details is essentially useless, or even dangerous if it leads to the wrong treatment. Always be as descriptive as possible about:
- Timing (when symptoms started, dosage times, etc.).
- Quantities and measurements.
- Precise location of injuries/conditions.
- Anything out of the ordinary that could be relevant.
Do not make assumptions; if you are unsure about some detail, it is better to note that than guess.
Staying Objective
While you want to include all relevant subjective information from the patient’s perspective, your professional documentation should remain as objective as possible. Avoid speculative language and unsupported conclusions. Stick to the facts you can observe and prove.
For example, don’t say “Patient seems depressed”. A better way to phrase it is “Patient reported feeling sad with low motivation and disinterest in normal activities”.
Correcting Mistakes Properly
Everyone makes mistakes sometimes, but proper error correction is crucial in healthcare documentation. A single strike-through on the error, initiated by you, with a date and reason for the change is generally the accepted way to correct. Never try to cover up, obscure, or overwrite mistakes.
Comprehensive and Well-Reasoned Notes
While concise and easily scannable notes are ideal, your documentation should back up any key points with clear rationale and supplementary details. For example, if ordering a special diet, note the specific reasons and medical evidence behind that recommendation.
Conclusion
Developing excellent documentation skills may seem tedious at first, but it will pay off immensely in the long run. Your diligent paperwork could literally save a life by preventing medical errors. It also protects you legally and professionally by creating a clear record of the care you provided.
Over time, good documentation habits will become second nature. Stellar documentation is a defining trait of a truly exceptional healthcare professional. Stay committed to accurate, comprehensive paperwork and it will raise your standards of patient care.
