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
Brilliant