Improving Patient Care Through Accurate and Complete Documentation
Tips and processes to help you get it right
Improving patient care is the goal of many healthcare personnel. After all, customers who receive stellar patient care are more likely to adhere to medical advice and treatments. They’re also more likely to take a proactive role in managing their disease, leading to better health outcomes.
While improving patient care often means enhancing access, reducing wait times, using sophisticated instruments/equipment, and training personnel, accurate and complete documentation is also crucial to achieving this goal.
What is Clinical Documentation?
Clinical or medical documentation is the process of recording information about the patient’s status, diagnosis, treatment, and outcomes. It highlights what medications were given and what tests or procedures were performed.
Documentation is rendered by personnel who are directly involved in the patient’s care, such as physicians, nurses, and therapists. Ideally, this should be done in real time, e.g., during or immediately after a treatment or procedure.
Clinical documentation is considered an essential element in the legal system, as failure to document pertinent information points to a deviation from the standard of care.
How Complete and Accurate Documentation Improves Patient Care
Here are five ways precise documentation affects patient care:
Influences Medical Decisions
Medical personnel see several patients per day, week, and month. As such, it may be hard for these professionals to remember what happened when they saw them before.
Complete and accurate documentation serves as a good ‘refresher’ of the diagnosis, medications, and procedures that the patient has received. Because it also reflects the outcomes (e.g., whether the patient has improved or worsened glucose control), it can help the healthcare provider decide whether to continue or change the treatments.
In essence, poor documentation may lead to bad diagnoses or treatments as it lacks the necessary information to make better medical decisions.
Improves Communication and Collaboration
Healthcare professionals may need to refer their patients to a specialist for management. Accurate documentation will help the specialist learn more about the patient’s case, such as their diagnosis, current treatments, etc., even without ‘actually’ talking to their primary healthcare provider.
Likewise, complete documentation will help the specialist make better treatment decisions. Moreover, it can help them avoid untoward reactions, such as prescribing medications that have an adverse interaction with the patient’s current pill.
Measures Quality of Care
Complete documentation can help determine the quality of care given in a certain institution. This promotes better patient care since documents bear the information needed for improving processes.
For example, documentation outlines the time it took for the patient to be seen, diagnosed, treated, and discharged. If this is slower than the recommended metrics, administrators and healthcare providers can brainstorm solutions to make the service more efficient.
Contributes to Research
In case the document is studied in the future, having complete information will help the researchers make sound and valid conclusions. Since accurate documentation helps with research, it indirectly contributes to better patient care.
According to a report, institutions that conducted more research had lower death rates for certain heart and lung diseases. According to experts, this is due to the intellectually stimulating nature of research, which can influence the way healthcare workers provide care.
Affects Insurance Reimbursements
Documentation influences insurance reimbursements, which have also been linked with service quality. This is especially true for value-based reimbursements, where payment is based on the quality of care provided. Insurance companies, after all, rely on accurate documentation and coding for payment.
Furthermore, incomplete documentation could lead to penalties. The incentives that the provider would have received could have been invested in sophisticated instruments/equipment, personnel training, and other programs that promote better patient care.
How to Improve Documentation
Given the far-reaching effects of documentation on patient care, it’s crucial for healthcare personnel to enhance their documentation skills. Here are some ways to do so:
Use the Right System
There are two types of patient recording systems: paper-based and electronic. The latter is preferred because it allows for better data collection, storage, and access. It also improves patient care by reducing medical errors caused by bad handwriting. It’s less time-consuming, allowing healthcare providers to focus on their patients more.
Attend ‘Refresher’ or Retraining Courses
Sometimes, healthcare personnel might need a ‘refresher course’ to be reminded of proper documentation practices, such as using the SOAP (subjective, objective, assessment, and planning) method, following the industry standards for documentation, etc.
Follow Document Review Recommendations
Some healthcare providers may not be aware of the ‘low’ quality of their documents. As such, it is crucial to hold a regular document review to check the accuracy and completeness of the information. This will help the auditors spot common errors and make the necessary recommendations for better documentation, not only for the provider but for the organization as a whole.
The Takeaway
Medical documentation, which is the process of recording vital patient information, plays a big role in improving patient care. Accurate and complete information can influence medical decisions, improve communication and collaboration, and measure the current quality of care. It can also contribute to research and affect reimbursements, both of which enhance patient experience.
Given the impact of clinical information, healthcare personnel must strive to improve their documentation. This can be done by using the right system, attending refresher courses, and following review recommendations.
