10 Tips for Effective Documentation

Does documentation feel like a chore? Given the pressures of limited time and new regulations, it’s understandable that many healthcare providers sometimes feel this way.

It might help to view documentation through a different lens.

Documentation tells the story of each patient’s journey throughout the entirety of each episode of care. From initial admission through the treatment process and discharge, important details are carefully noted, allowing you and other caregivers to spot patterns and potential challenges so you can provide the absolute best level of care possible and avoid potential setbacks.

With that in mind, these tips will help you document more effectively and efficiently to communicate crucial information to those who need it.

10 Tips for Better Documentation

1. Remember that any reviewer of a patient record does not have the depth of knowledge that is gained from providing care. Because of this, document objective and clear findings and information, including the patient’s problems and needs, the care provided, and how the care is directed toward goal achievement and discharge.
2. The contents of the documentation should convey to any reader, such as your manager, a state or accreditation surveyor, or a payer, the status of the patient, adherence to the ordered plan of care, and progress toward individualized patient-centered goals.
3. Document both medical necessity and homebound and support other coverage criteria in your documentation. For home care and hospice care, use objective descriptive terms that help the reviewer “see” your patient and their functional and other limitations that support a knowledge of the tenets of coverage for your program.
4. Look at the documentation objectively. Does it tell the story of the patient, their care trajectory, and the interventions provided and implemented based on physician orders?
5. Make sure calls and other communication across team members and the physician are documented. If the patient experiences a change in condition, does the documentation explain what the findings were or what occurred with the patient that necessitated the call? Does it include what actions were ordered or changed and implemented as well as the patient’s response to these interventions and care?
6. Are the patient’s areas of risk for hospitalization noted and observed? Are the interventions to prevent this reoccurrence documented?
7. Does each visit by a clinician include the elements of assessment, care planning, interventions and actions, and continued evaluation?
8. Documentation should include patient and family caregiver education, their responses to and demonstration of the education provided, as well as results of the education (for example, medication administration).
9. The care entries and overall information need to reflect the level of care expected by healthcare consumers, caregivers, and their families.
10. Overall, the clinical documentation should demonstrate compliance with regulatory, licensure, and quality standards. Ask yourself the value question: Would I pay for this care or visit? Is this reflected in the clear documentation that supports medical necessity and coverage?

Need additional assistance developing or advancing your documentation skills? Be sure to check out the following MedBridge courses:

• Identifying, Communicating, & Documenting Patient Change in Condition
• Orientation: An Overview of Documentation Requirements in Home Care
• Medicare Coverage and Documentation Requirements: The Fundamentals

Adapted from the “Handbook of Home Health Standards: Quality, Documentation and Reimbursement.” (Marrelli, 6th ed). Reprinted with permission. www.marrelli.com