Medical Documentation


Medical Documentation, Clinical Report Documentation, Patient Documentation, Encounter Documentation

  • See Also
  1. Computerized Medical Record (Electronic Medical Record, Electronic Health Record, EMR, EHR)
  2. Clinical Decision Support (CDSS)
  3. Clinical Practice Guideline
  4. Knowledge Representation Syntax (Clinical Guideline Modeling Method)
  5. Meaningful Use of the Electronic Health Record
  6. Electronic Prescription (E-Prescribe, e-Rx)
  • Pearls
  • Medicolegal
  1. Be accurate
    1. Review canned phrases (boilerplate, macros) in electronic records
    2. Avoid copying and pasting sections from another of the patient's encounters
      1. If used, copied sentences should be denoted in quotes and referenced to the source of the quote
      2. Copying propogates medical errors and artificially increases encounter coding
      3. Centers for Medicare and Medicaid Services (CMS) sees copying/cloning records as fraud
    3. Do not blindly insert text for history or exam elements that were not completed
      1. Example: PERRLA includes accommodation, which is often documented, but not actually tested
    4. Never alter or edit prior records
  2. Be complete
    1. Lawyers mantra: "not charted, not done"
    2. Review nursing notes and Vital Signs (and address differences in real time)
    3. Record interval progress notes with time stamps
      1. Interval of at least hourly (more often for more serious presentations)
      2. Targeted update based on results, changing signs and symptoms, and response to interventions
    4. Avoid time delays in documentation
      1. Late entries should be time stamped
    5. Medical decision making
      1. Documenting a coherent Thought Process is among the most important parts of the medical record
  3. Be consistent
    1. Always confirm you have opened the correct patient record first (before review, writing orders, medical decision making)
    2. Last Line of plan (and do this with every patient)
      1. Assessment and plan reviewed with patients
      2. Patients questions answered
  4. Be objective
    1. Do not write what you would not want the patient to read
      1. Avoid disrespectful comments in the medical record
    2. Do not criticize in the medical record
      1. A patient's negative comments about prior care (if medically relevant) should be in quotations
  5. Be legible
    1. Avoid confusing abbreviations
    2. Correct errors on paper correctly
      1. Errors in a paper record should be corrected with a single strike-through line, with initials and date
  6. Do not put non-relevant, discoverable information in record
    1. Do not speculate on cause of a complication
      1. Example: Perinatal asphyxia causing Cerebral Palsy
    2. Do not admit guilt or blame in the medical record
    3. Avoid non-neutral phrases in text (e.g. mistake)
    4. Do not document legal Consultation in record
    5. Do not put incident reports or reference to such reports in the medical record
    6. Do not document conflicts between clinical or administrative staff in the medical record
    7. Avoid putting disclaimers in the record (e.g. "excuse inaccuracies due to ...")
  7. References
    1. Henry (2013) Avoid Being Sued, EM Bootcamp, CEME
  • Management
  • Miscellaneous
  1. Patient Reported Outcome Measures (PROM, e.g. GAD-7, PHQ-9, CAGE)
    1. Improve diagnosis and documentation
    2. Improve patient-provider communication and trigger management changes
    3. Gibbons (2021) Cochrane Database Syst Rev (10):CD011589 [PubMed]