Have you ever been to the doctor and seen them writing something down on either a piece of paper or on an electronic device? This is called medical documentation and it is a crucial foundation of everything in the medical field.
Why Medical Documentation Is Important
It’s not only a crucial part, but also it is legally necessary when it comes to practicing medicine. However, making sure you do it well has many benefits beyond the legal system.
Medical documentation can be used to affect the quality of the care you give to patients and even influence the funding of hospitals. Every document of service within a hospital gets coded and billed into a cost for the hospital. These costs set budgets and funding.
It also is a form of communication between all those involved in treating patients. When transferring practice or doctors, if the doctor before took good notes on the care you received, it will make it easier on anyone else who will treat you in the future.
Basics of Medical Documentation
There are some basics that need to be followed that are taught almost universally when it comes to medical documentation and its procedures:
- Date, Time, and Sign everything: While this may seem simple, it is everything but simple. This step should not be overstated as it can be critical in piecing together many aspects of a patient’s care.
- Enter as care is given: Whenever care is given to a patient, you should be inputting it into the document. It will help to make sure you do not forget to put down key details as time goes on.
- Make sure you are legible: Just like turning in a paper while in school, there’s no point in taking notes if no one can read them, even if just you are reading them.
- Be Professional: When dealing with a patient you should always remain professional. Attempting to be sarcastic or making casual jokes is always a bad look.
- Fix your mistakes: Fix your mistakes as soon as you make them. Ensure your fixes are legible and you date them when you make corrections.
There’s a method within medical documentation called the SOAP Method which stands for Subjective, Objective, Assessment, and Plan:
- Subjective: This means to put down the current conditions of the patient but in a narrative form. This includes the patient’s complaints and if they are onset, chronic, the quality of them, and the severity. You should use the patient’s own words when documenting this.
- Objective: This is where you document the repeatable and measurable facts. This could include the “Patient appears pale.” Also include vital signs, any laboratory results, IV fluids, age, weight, etc.
- Assessment: This method is used to document the primary diagnosis. If a diagnosis has been made, then you can use this section to comment on if the patient is getting better or deteriorating. A complete list should be done every 1–2 days in this section or when a new issue comes up.
- Plan: This section is used for creating a treatment plan along with any further testing or even referrals. If the patient is admitted to a hospital, you should include a likely discharge date as that can help the unit’s Nurse Manager.
How Much to Write
When it comes to medical documentation, writing too little or much can both have pros and cons.
While writing good records is always the goal, if a patient goes to an after-hours doctor, such as urgent care, sometimes the attending doctor or nurse does not have the time to read through the details of a patient’s chart. So sometimes writing more is not always better.
On the other side of that, if you write too little, the next medical professional to provide care for your patient may not be able to provide it effectively.
It can be effective for both the next attending professional and your patient to keep good and clear documents of their medical history for further treatment as you will not always be the attending personnel to treat them.
Meeting Types to Document
You should document all types of meetings in the medical field. However, how you document a telehealth meeting versus a family meeting is different:
- Phone Conversation: When doing a telehealth or phone conversation it is often not thought of to document it. You should always document conversations with those related to the patient, other medical professionals or anyone involved in treating your patient.
- Family meetings: This may be one of the hardest ones to provide medical documentation for. Family meetings can be unstructured and have a weird conversation flow. However, many key decisions are made in these types of conversations. It is also key to document who is there and their roles in the conversation as well as the relationship to the patient.
If you’ve ever left the hospital, they have given you a packet of information called your ‘Discharge Paperwork’ and it is another part of medical documentation procedures. The way discharge papers are structured is:
- Diagnosis: What did you come in with and what does it mean?
- Comorbidities: Anything that was there upon admission and treated.
- Complications: Any conditions that exist beyond the initial diagnosis, may come up during the length of the stay.
- Procedures: Anything that required anesthesia, sedation, or injection.
- Discharge Medicine List: This will outline any medication and the changes that were made.
- Discharge plan: This will include any follow-up appointments and include instruction to seek medical help if things do not improve or worsen. It will also include directions to follow up with your primary care physician after being discharged.
If you’re a patient or even a medical professional, understanding medical documentation is an important part of the medical treatment process. Having good medical documentation will not only help you if you do long-term treatment of a patient but will also help any other medical professional who will also treat them. It will let the patient get the care they need in a timely fashion.
Whether you need a team of consultants to produce a complete line of documentation or a single technical writer for a brief project, Essential Data’s Engagement Manager will lead the project from start to finish. At Essential Data Corporation, the quality of our work is guaranteed. Contact us today to get started. (800) 221-0093 or firstname.lastname@example.org
By Dylan Friebel