Clinical Documentation

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Introduction

  • Good documentation is easy to follow, provides a logical explanation of the conclusions made, the response to interventions and makes clear the way forward
  • Bad documentation results in misled conclusions, uncertain outcomes and stuttering plans

Purpose

  • Logically describes what the main problems or issues are
  • Provides an investigative plan or management plan
  • Forms a legal document that is particularly scrutinised for omissions in the assessment or management that resulted in missed diagnosis or adverse outcome
  • As a permanent record, is more thorough then Clinical Handover

Key aspects

  • A chronological narrative of the problem – symptoms, prior investigations, consultations, treatment and response (if there are several problems, group these narratives separately)
  • Additional supporting evidence of the diagnosis e.g. PMHx, FMHx, medications, risk factors
  • Relevant negative findings or absent risk factors that would have suggested alternative diagnoses (vitally important if an adverse event occurs)
  • The diagnosis (and the differential diagnoses to exclude) – which should summarise the underlying causes and severity
  • Additional psycho-social or medico-legal issues that may constrain assessment or management
  • The rationale of the Investigative strategy and the actions depending on results
  • Consultations requested and reason
  • Treatments given and response observed
  • Initial management plan
  • Comprehensive management plan once all information available
  • Patient discussion and information provided
  • Communications to other health professional regarding treatment, monitoring or follow-up – and contingency plan if complications develop or condition deteriorates

 

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