By Greg Freeman
Clinicians should be reminded that proper documentation is not only about providing a legal defense, says Annika Kariniemi, MSN, RN, APRN, CNP, founder of ProHealth Medical Weight Loss in Phoenix.
“It’s not just about keeping track of medical history. It’s also essential for ensuring quality of care, fostering effective communication among healthcare teams, and protecting both patients and clinicians in case of legal issues,” she says. Kariniemi offers these best practices for documentation in healthcare, as well as common pitfalls and ways to avoid them:
- Be clear and simple: Always write in a way that is easy to understand. Avoid complicated jargon or vague language. Anyone should be able to read your notes and know exactly what happened with the patient.
- Document promptly: The sooner you document, the better. Try to make your notes right after interacting with the patient to avoid forgetting important details.
- Stick to the facts: Be thorough, accurate, and objective. Your notes should reflect what you observed and what was discussed with the patient, without personal opinions or assumptions.
- Use standard forms: Many healthcare settings use templates to help capture the necessary information in a consistent way. These forms ensure that important details are not missed.
Policies and Procedures
Hospitals and clinics typically have specific rules about how documentation should be done, which Kariniemi says should include these points:
- Confidentiality: It is crucial to follow HIPAA guidelines and keep all patient information private.
- Correcting mistakes: If you make an error, follow the correct process for fixing it. Usually, this means striking through the mistake, writing the correction, and initialing it, instead of deleting or altering original entries.
- Electronic medical records (EMRs): With most places using EMRs now, it is important to follow the guidelines for signing in and out of the system and making sure everything is properly logged and dated.
How Documentation Loses Value in Legal Disputes
Clinicians also must understand how poor documentation can hurt in legal situations. Kariniemi says these are some of the biggest issues she has seen with documentation:
- Ambiguity: If your notes are unclear or vague, they can be interpreted in different ways, which could work against you in a legal case.
- Inconsistencies: If the documentation contradicts itself or does not show a clear, consistent care plan, it can raise questions about the quality of care provided.
- Missing signatures and dates: If the documentation is missing a
signature or date, it can be hard to prove when something happened, which might be crucial in legal disputes. - Omitting critical information: Leaving out key details like assessments, changes in the patient’s condition, or treatment plans could undermine the validity of the entire record.
Habits to Watch for Among Clinicians
Some habits among clinicians can negatively impact documentation. Kariniemi offers a few to keep an eye on:
- Rushed or incomplete entries: In fast-paced environments, clinicians might rush through their notes, which can lead to mistakes or omissions. It is important to make time for accurate documentation, even when things are hectic.
- Not paying enough attention to detail: Some might assume they do not need to write everything down, but every detail matters. A missing note or an unclear entry can cause problems down the road.
Areas of Medicine with Documentation Issues
Certain medical areas are more prone to documentation issues, Kariniemi says. For example, the fast-paced nature of emergency care can lead to rushed or incomplete documentation. It is vital to make sure that every aspect of patient care is documented, even in a crisis, she says.
In surgeries, it is essential to document everything — preoperative assessments, consent forms, anesthesia details, and post-op care. Missing or incomplete notes in these areas can have serious legal consequences, she says. Documentation in psychiatry is especially important, since it needs to reflect patient assessments, treatment decisions, and any changes in their mental health status, Kariniemi says. Inadequate documentation here can be dangerous, particularly when dealing with high-risk patients, she says.
Reducing Documentation Problems
Kariniemi suggests these ways to better documentation:
- Regular audits: Conducting periodic reviews of documentation can help identify areas that need improvement and ensure that everyone is following the right procedures.
- Encouraging reflection: Clinicians should make it a habit to reflect on their documentation as part of their routine. Using checklists or reminders can help ensure that nothing is missed.
- Improving communication: Clear communication among the healthcare team reduces the chances of miscommunication being reflected in the documentation. When everyone is on the same page, documentation is much more accurate.
“High-quality documentation is key to effective care, patient safety, and protecting both clinicians and patients legally,” Kariniemi says. “By following best practices, avoiding common mistakes, and keeping an eye on problem areas, healthcare teams can make sure their documentation is strong and reliable.”
Source
- Annika Kariniemi, MSN, RN, APRN, CNP, ProHealth Medical Weight Loss, Phoenix, AZ. Telephone: (602) 329-4426. Email: [email protected].
Greg Freeman has worked with Relias Media and its predecessor companies since 1989, moving from assistant staff writer to executive editor before becoming a freelance writer. He has been the editor of Healthcare Risk Management since 1992 and provides research and content for other Relias Media products. In addition to his work with Relias Media, Greg provides other freelance writing services and is the author of seven narrative nonfiction books on wartime experiences and other historical events.
Clinicians should be reminded that proper documentation is not only about providing a legal defense.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content