Documentation: Dos & Don’ts

Ask any healthcare professional why they entered their field; the answer will likely be to help people. You probably will encounter few, if any, that will tell you it was to spend extra time charting. However, this documentation is crucial to the care we provide. There are three aspects when providing services in which accurate documentation is imperative.

First, consider the patient. As a practitioner, it is crucial to document encounters accurately. Documentation often used in health care is referred to as SOAP notes. These notes provide a subjective and objective narrative, an assessment, and a plan for the patient. During subsequent patient encounters, these initial notes provide good documentation for the treatment and progression of your patient and the relationship with that patient.

Now consider another perspective–that of another provider. Documentation completed by other providers can give you an understanding of the patient, history of diseases, previous treatment options, etc. Good documentation on the part of the previous provider of the transition to the next provider’s care. Terrible documentation can lead to unnecessary tests, treatment, and time to help your patient.

The third consideration for good documentation is third-party billing. No matter what healthcare role you fall into, third-party billing is probably at least part of your business. Good documentation for billing provides an opportunity to prove why certain services were needed or utilized. It also provides a platform to protect third-party programs.

There are seven characteristics of high-quality clinical documentation:

1. Concise

2. Complete

3. Reliable

4. Legible

5. Precise

6. Timely

Documentation can be electronic or hard copy. If you are using electronic documentation, here are a couple of additional tips:

  1. Ensure documentation is accurate initially. Many times, fields are self-populating, leading to information being copied over and over incorrectly.
  2. Print patient records occasionally to review the flow and verify that the information is presented in a way that makes sense to third-party readers.
  3. Verify audit trails. Ensure your documentation system can verify who is accessing the record when certain aspects of the record were reviewed—any changes made to a record, including who made changes and when the changes were made.

To learn more about other pharmacy issues and what you can do to protect yourself and your business, visit the Risk Management Center (RMC). The RMC is available at no cost to Pharmacists Mutual’s commercial insurance customers at Click “My Accounts” in the upper right corner to access or enroll.

The principles in this article came from:

  1. Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practice. Chicago: AHIMA Press, 2017.
  2. The official transcript from Julie Taitsman, Chief Medical Officer for the US Department of Health and Human Services, Office of Inspector General, on January 30, 2012.