{"id":943,"date":"2016-09-14T11:27:02","date_gmt":"2016-09-14T11:27:02","guid":{"rendered":"http:\/\/emedsa.org.au\/CoreMed\/?p=943"},"modified":"2016-09-18T12:05:38","modified_gmt":"2016-09-18T12:05:38","slug":"clinical-documentation","status":"publish","type":"post","link":"http:\/\/emedsa.org.au\/CoreMed\/2016\/09\/14\/clinical-documentation\/","title":{"rendered":"Clinical Documentation"},"content":{"rendered":"<p><a href=\"http:\/\/twitter.com\/share?url=http%3A%2F%2Femedsa.org.au%2FCoreMed%2F2016%2F09%2F14%2Fclinical-documentation%2F&amp;count=none&amp;text=Clinical Documentation - CoreMed\" class=\"twitter-share-button\">Tweet<\/a><\/p><p><strong>Introduction<\/strong><\/p>\n<ul>\n<li>Good documentation is easy to follow, provides a logical explanation of the conclusions made, the response to interventions and makes clear the way forward<\/li>\n<li>Bad documentation results in misled conclusions, uncertain outcomes and stuttering plans<\/li>\n<\/ul>\n<p><strong>Purpose<\/strong><\/p>\n<ul>\n<li>Logically describes what the main problems or issues are<\/li>\n<li>Provides an investigative plan or management plan<\/li>\n<li>Forms a legal document that is particularly scrutinised for omissions in the assessment or management that resulted in missed diagnosis or adverse outcome<\/li>\n<li>As a permanent record, is more thorough then <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/16\/clinical-handover\/\">Clinical Handover<\/a><\/li>\n<\/ul>\n<p><strong>Key aspects<\/strong><\/p>\n<ul>\n<li>A <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/18\/case-formulation\/\">chronological narrative of the problem<\/a> &#8211; symptoms, prior investigations, consultations, treatment and response (if there are <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/18\/clinical-reasoning-razors-and-dictums\/\">several problems<\/a>, group these narratives separately)<\/li>\n<li>Additional supporting evidence of the diagnosis <em>e.g. PMHx, FMHx, medications, <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/01\/pathology-aetiology\/\">risk factors<\/a><\/em><\/li>\n<li>Relevant <strong>negative findings\u00a0<\/strong>or absent risk factors\u00a0that would have suggested alternative diagnoses (vitally important if an adverse event occurs)<\/li>\n<li>The diagnosis (and the differential diagnoses to exclude) &#8211; which should summarise the underlying <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/01\/pathology-aetiology\/\">causes<\/a> and <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/07\/27\/evaluating-severity-clinical-assessment\/\">severity<\/a><\/li>\n<li>Additional psycho-social or medico-legal issues that may constrain assessment or management<\/li>\n<li>The rationale of the Investigative strategy and the actions depending on results<\/li>\n<li>Consultations requested and reason<\/li>\n<li>Treatments given and response observed<\/li>\n<li>Initial management plan<\/li>\n<li>Comprehensive\u00a0management plan once all information available<\/li>\n<li>Patient discussion and information provided<\/li>\n<li><a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/08\/16\/clinical-handover\/\">Communications to other health professional <\/a>regarding treatment, monitoring or follow-up &#8211; and contingency plan if complications develop or condition deteriorates<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>TweetIntroduction 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&#8230; <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/09\/14\/clinical-documentation\/\">Read more &raquo;<\/a><\/p>\n","protected":false},"author":1,"featured_media":944,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"episode_type":"","audio_file":"","cover_image":"","cover_image_id":"","duration":"","filesize":"","date_recorded":"","explicit":"","block":"","filesize_raw":"","footnotes":""},"categories":[1],"tags":[],"class_list":["post-943","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/943","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/comments?post=943"}],"version-history":[{"count":6,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/943\/revisions"}],"predecessor-version":[{"id":960,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/943\/revisions\/960"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/media\/944"}],"wp:attachment":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/media?parent=943"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/categories?post=943"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/tags?post=943"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}