It’s probably happened to you a million times while flipping through your notes: the handwriting is barely legible, full of jargon you may have already forgotten, and doesn’t give you a clear picture of what happened or what issues still need to be addressed. Sound familiar?
Most medical practitioners have been there, which is why good medical documentation is absolutely essential for providing quality care and avoiding mistakes.
But, it’s a skill that takes practice to master. Don’t worry, though!
In this article, we’ll cover what medical documentation is, why it matters, and give you some tips and tools to ace it every single time.
We’ll go over:
Let’s get started!
In a nutshell, we refer to medical documentation as the written records of a patient's medical care.
It includes notes from doctors, nurses, and other healthcare professionals about a patient's condition, treatment, and progress.
There are several purposes for comprehensive medical documentation, and they are:
In the event of legal inquiries or even all-out disputes, medical documentation can protect healthcare providers by demonstrating adherence to standards of care and informed consent.
How? By providing the necessary evidence to support claims for medical services rendered, detailing the care provided, and justifying the costs incurred.
They offer a nearly bottomless source of data for clinical studies, helping to identify trends, outcomes, and areas for improvement.
Reliable medical documentation goes way beyond scribbling notes with barely legible handwriting. There’s a method to the madness, called SOAP.
It stands for:
Following the SOAP format is part and parcel of providing solid and reliable medical notes.
Also, don’t forget to date and sign all entries, use approved medical abbreviations, and avoid vague or ambiguous language.
Finally, proofread carefully to make sure that there are no spelling, grammar, or punctuation errors before entering the record into the EHRs (Electronic Health Records).
Medical documentation is equally important across all medical professions. However, the focus and level of detail can differ between professions.
Let’s take a look at an example comparison:
Nurses typically document more frequently, recording vital signs, input/output, wound care, ADLs, and other routine care.
Nurses set out to capture the patient’s condition and response to treatments, which means they typically note subjective symptoms described by the patient and objective observations.
The medical documentation should be clear, concise, and include:
These nurse notes give doctors a glimpse into the patient’s status between rounds so they have the full picture when assessing the patient.
Doctors have a big focus on diagnostic and therapeutic decision-making. Therefore, they document medical history, examination findings, differential diagnoses, test orders, and treatment plans.
Doctors are looking to justify diagnoses, treatment plans, and discharge.
So, their notes should capture:
As we mentioned above, doctors depend on nursing documentation to understand how the patient has progressed and responded since the last visit.
Together, these nursing and medical notes paint a complete picture of the patient's hospital stay and the care provided.
Medical documentation is a tedious, painstaking process, but it's essential for providing quality care and protecting patients and providers.
By following best practices like SOAP - focusing on relevant details, keeping it simple and clear will help you document efficiently while covering all the bases. Even if it takes time, the alternative is providing worse care, and we know that’s not a real option!
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