How can you effectively document patient care when working with physicians?
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Documentation is a vital part of patient care, as it records the history, diagnosis, treatment, and outcomes of each encounter. However, documentation can also be challenging, especially when working with physicians who may have different expectations, preferences, and styles of communication. How can you effectively document patient care when working with physicians? Here are some tips to help you.
When documenting, it is important to keep in mind that your documentation should serve multiple purposes, such as providing timely and accurate information, supporting quality improvement, and meeting legal and ethical standards. Additionally, it should be tailored to the specific audience who will read it. You should therefore consider questions such as the main goal of your documentation, who will be reading it, the level of detail and language they expect, and how they will access it. By understanding the purpose and audience of your documentation, you can ensure that it is relevant, clear, and appropriate for the situation.
Your documentation should also comply with the standards and guidelines of your organization and profession, as they provide the framework and criteria for effective and consistent documentation. For example, you should follow the policies and procedures of your organization regarding the format, frequency, and content of your documentation, as well as the use of abbreviations, symbols, and signatures. You should also adhere to the principles and standards of your profession, such as the nursing process, the SOAP (subjective, objective, assessment, plan) format, or the SBAR (situation, background, assessment, recommendation) technique. Additionally, you should be familiar with the legal and ethical implications of your documentation, such as the confidentiality, privacy, and security of patient information, the accountability and liability for your actions, and the evidence and justification for your decisions.
By following the standards and guidelines of your organization and profession, you can ensure that your documentation is accurate, complete, and consistent.
It is important for your documentation to reflect your communication skills and professional relationships with physicians, as they have a direct effect on the quality and safety of patient care. To ensure that your documentation is collaborative, informative, and respectful, you should communicate effectively and respectfully with physicians, both verbally and in writing. This includes using clear and concise language, avoiding ambiguity or slang; providing relevant and accurate information; using appropriate tone and style; acknowledging and addressing any questions or feedback from physicians; seeking clarification and confirmation when in doubt or disagreement; and documenting any communication with physicians. By following these best practices, you can ensure that your communication is professional and effective.
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Ella Nelson, MD, MBA, FISQua
Chief Medical Informatics Officer | Health Tech Start-up | Non-clinical Career Transition | Aspiring Health Care C-suite Executive
I have personally witnessed physicians from different departments disagree and go back and forth with each other about the care plan for a shared patient. Unfortunately, in some of those instances, the arguments were made and written in the patient’s chart. Clearly, best practices regarding documentation were not upheld. Health care is multifaceted and would involve multidisciplinary teams. As such, disagreements regarding care are bound to occur, but those should take place in grand ward rounds, multidisciplinary team (MDT) meetings, etc., and not the patient’s chart.
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It's important to keep your documentation up to date and reflective of the current status and progress of patient care, as this affects the continuity and quality of care. Therefore, it's imperative to review and update your documentation regularly, particularly if there are changes in condition, interventions, or outcomes. For instance, you should document as soon as possible after each encounter to avoid delays or gaps, any changes in assessment, diagnosis, treatment, or goals, any interventions performed and their indications, procedures, and results, any outcomes observed and their responses, complications, and follow-ups, any referrals or transfers made with their reasons, actions, and outcomes, as well as any education, counseling or support provided with the topics, methods and outcomes. By reviewing and updating your documentation regularly you can ensure that it is current, comprehensive and relevant.
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Ella Nelson, MD, MBA, FISQua
Chief Medical Informatics Officer | Health Tech Start-up | Non-clinical Career Transition | Aspiring Health Care C-suite Executive
It is also worth noting that timely reviews and updates of clinical documentation ensures that patient charts are signed off and closed early. In some instances unsigned or late documentation results in unbillable patient charts. Under no circumstances should a patient’s chart be left opened, unsigned, or undocumented for an extended period of time.
Your documentation should be a source of feedback and improvement opportunities, allowing you to evaluate and enhance your performance and practice. You should thus ask for feedback from various sources, such as peers, supervisors, physicians, patients, or quality committees. This feedback can be used to review the document's strengths, weaknesses, and areas for improvement. After making corrections, adjustments, or changes based on the feedback, you should also seek improvement opportunities such as attending training, workshops, or seminars. Sharing best practices, tips, or resources can further help you ensure that your documentation is reflective, responsive, and progressive. This is especially important for nurses who work with physicians as it affects the quality and safety of patient care. By following these tips, you can effectively document patient care when working with physicians and boost your professional competence and confidence.
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Ella Nelson, MD, MBA, FISQua
Chief Medical Informatics Officer | Health Tech Start-up | Non-clinical Career Transition | Aspiring Health Care C-suite Executive
1. Poor documentation is a cause for concern as it affects quality of care, compliance and billing processes. 2. If it was not documented, then it was not done!