Clinical documentation is an important part of clinical care. It serves as a record of the care provided and the excellence in clinical service. Documentation should be clear, concise, thorough, and well organized to meet the clinical standard of care for your patients as well as the needs of your colleagues, institution, and governing compliance and financial agencies. The use of the electronic health record (EHR) can aid in documentation efficiency, particularly when it is personalized to your clinic workflow patterns, but can also create burden and contribute to work burnout when not optimized. Team-based models of care and additional advances in technology can also improve efficient documentation practices. Finally, challenges to maintaining documentation standards and solutions are discussed.

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How to Maintain Excellent Clinical Documentation

  • Sharon E. Williams,
  • Rachel C. Lawton

摘要

Clinical documentation is an important part of clinical care. It serves as a record of the care provided and the excellence in clinical service. Documentation should be clear, concise, thorough, and well organized to meet the clinical standard of care for your patients as well as the needs of your colleagues, institution, and governing compliance and financial agencies. The use of the electronic health record (EHR) can aid in documentation efficiency, particularly when it is personalized to your clinic workflow patterns, but can also create burden and contribute to work burnout when not optimized. Team-based models of care and additional advances in technology can also improve efficient documentation practices. Finally, challenges to maintaining documentation standards and solutions are discussed.