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 Table of Contents  
PRACTICE POINT
Year : 2018  |  Volume : 10  |  Issue : 6  |  Page : 209-214

How to write an effective clinical document?


1 Department of Surgery, Commonwealth Healthcare Corporation, Saipan, Northern Mariana Islands
2 Department of Medicine, Faculty of Medicine, University of Tripoli, Tripoli, Libya

Date of Web Publication10-Dec-2018

Correspondence Address:
Dr. Ali M Ghellai
Department of Surgery, Commonwealth Healthcare Corporation, Saipan
Northern Mariana Islands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmbs.ijmbs_72_18

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  Abstract 


Medical records are the most important practice tools used by doctors in their daily practice, regardless of specialty. The rule of thumb is “If it is not documented, it does not exist.” Deficiencies in the clinical documentation have been directly linked to increased incidence of adverse events and medical errors with resulting patient injury. Doctors are required to keep accurate and comprehensive medical records that will stand alone without their interpretation. An excellent medical record should be clear, concise, complete, accurate, and current factual record of clinical care. That must be recorded in a legible chronological and a confidential way while avoiding duplications and abbreviations. Written communication is vital to patients' quality of care, and thus this paper is dedicated to the basic written communication skills and concepts that are foundational to all healthcare professionals. In this practice point, we provide standardized templates for most common written documentation by physicians.

Keywords: Documentation, medical records, progress notes, written communication


How to cite this article:
Ghellai AM, Elhafi KM, Ghellai MA. How to write an effective clinical document?. Ibnosina J Med Biomed Sci 2018;10:209-14

How to cite this URL:
Ghellai AM, Elhafi KM, Ghellai MA. How to write an effective clinical document?. Ibnosina J Med Biomed Sci [serial online] 2018 [cited 2021 Dec 1];10:209-14. Available from: http://www.ijmbs.org/text.asp?2018/10/6/209/247166




  Introduction Top


Written documentation of patient encounters is a necessary skill for all medical disciplines. Communication is crucial to quality care that the Accreditation Council for Graduate Medical Education included interpersonal and communication skills as one of the six core competencies.[1],[2] Doctors are required to keep accurate, comprehensive medical records that will stand alone without the need for their interpretation. In addition to meeting professional and medico-legal requirements, good medical records will assist doctors and his/her colleagues in offering comprehensive, effective and efficient care for patients. On the other hand, the breakdown in written and verbal communication have been directly linked to increased incidence of adverse events and medical errors with resulting patient injury.[3],[4] While verbal communication skills are taught and assessed in medical schools, medical students report limited instruction in written communication skills which is often informal through a hidden curriculum and lack formal feedback.[5],[6] In a longitudinal study by Maguire et al. assessing how physicians' communication skills changed over their careers.[7] It was found that, without explicit intervention, most of the skills physicians acquired tended to be fixed in place by the end of residency. That is somewhat alarming! Common physicians problems while completing medical records are (i) neglecting to do a proper history and physical on every patient. (ii) failing to write a note: Some physicians make rounds and pass the nurses' station to give verbal instructions but without placing a progress note, sometimes not even a history or physical on the chart. (iii) forgetting to place an operative note in the chart instantly after a procedure or operation is performed. (iv) writing illegible and overuse of non-standardized abbreviations. (v) not entering the time and date or signing their notes. (vi) using the nonspecific phrases, “doing well” or “no change.” This does not tell anyone what has happened on that incident. (vii) failure to note speaking to relatives or family about findings. (viii) not stating a diagnosis (or provisional diagnosis) when ordering investigations or treatments: Consistently, specify the condition that is being assessed or treated when prescribing medication, sending patient to laboratory or imaging, or starting a treatment.

Medical records are the most important practice tools used by doctors on a daily basis, regardless of specialty and the rule of thumb is “If it is not documented, it does not exist.” This paper is dedicated to the basic written communication skills and concepts that are foundational to all healthcare professionals. We will provide standardized templates for most common written documentation by physicians. Macros and templates may be helpful in improving the completeness and efficiency of documentation.[8] The primary purpose of clinical documentation is to facilitate excellent care for patients. Documentation is essential to record pertinent facts, findings, and observations regarding a patient's health history including past and present illnesses, examination findings, results of tests, the nature of treatments, and outcomes. Good medical record should be clear, concise, complete, accurate, and current factual record of clinical care. That must be recorded in a legible chronological and a confidential way while avoiding duplications and abbreviations.[9],[10]. Examples of written documentation are listed in [Table 1]. All orders should invariably be signed, dated, and timed.
Table 1: Examples of written documentation

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  Common Written Documentation Top


Ideal history and physical

This is the cornerstone of the patient's admission as far as medical decision making goes. It is the single most referred-to note in the chart, the one every consultant, resident and nurse will turn to for information on the patient. It should be structured as follows:

  1. History of present illness (HPI): The first sentence should be kept short, precise and containing meaningful and relevant information, for example: “A 67-year-old woman with known CAD and T2DM who presents with crushing, substernal chest pain.” Keep it very short and to the point, including only those facts that directly relate to the ultimate diagnosis. In most of the times, HPI when done well, it should generate the right answer to a diagnostic dilemma before any test is ordered


  2. The next paragraph should include a thorough analysis of the patient's complaint using the FAR COLDER system: Frequency, associated symptoms, radiations, character, onset, location, duration, exacerbating factors and relieving factors. Then, ask and answer all the pertinent review of systems (fever, +shortness of breath, no nausea or vomiting) that relate to the condition you believe the patient has

  3. Review of systems: It should not include any repetition of information already mentioned in the past medical history (PMH) or the HPI
  4. PMH: It covers all medical conditions and when they were diagnosed as well as previous surgeries and when they were performed
  5. Medications list and Allergies: Include the name of the offending agent as well as the specific reaction it causes
  6. Social history and family history
  7. Physical examination, vitals, and laboratory studies
  8. Assessment and plan (A/P): This is where you put your diagnosis; explain why you think it is correct, other things you considered and excluded and what you plan to do about it. Write this out in a problem-based format touching on the chief complaint as well as anything else you will be treating including chronic active conditions.


Admission order

A typical admission set of orders is shown in [Box 1]. The mnemonic for this is usually referred to as ADCA VAN DISML. All medications need a: Dose, route (PO, PR, or IV) and frequency (e.g. q6 h). All blood pressure medications should have parameters for when they should be held (e.g. hold labetalol for systolic blood pressure [SBP] <120 or heart rate [HR] <60). Verbal orders are often required in emergency situations but should be avoided otherwise. These orders need to be signed within 24 h. End the admission orders by giving nurses parameters when to call a house officer (for example T >38.5, HR >130 or <60, SBP >180 or <90, respiratory rate >30, O2 Sat <92%, mental status changes, or any acute change in patient's condition). Diet should be specified according to the clinic state [Box 2].



Progress note

It is both required and essential to write a note on every patient every day. It should be something that the author and his/her colleagues can refer to know exactly what has happened to the patient, any recent changes or events and what was done or is planned to be done [Box 3]. Best is to imagine that one is writing it so that a consultant can be kept up to date or a cross cover resident in the middle of the night can know precisely what is happening with a patient with whom he may not be very familiar.



Progress notes are usually documented in a defined structure. This format is referred to as SOAP note; the acronym represents the first letters of the words subjective, objective, assessment, and plan. This note, ideally summaries all past 24 h events, tests, and consults as well current assessment and management plans. If postoperative, always ask about incisional pain and response to pain medications, any fever, nausea or vomiting. Also, document ambulation, voiding, passing flatus and bowel movements.

Event note

It should be written for all unexpected events and should summaries the event and written in SOAP format. Subjective: events and complaints, objectives: vitals, physical examinations, laboratories, and test results, current assessment and management plans, including procedures and consultations as well communications with seniors colleagues, other specialties or with patient and family.

Preoperative note and orders

Preoperative note is an essential checklist written in progress notes before any planned operative procedure [Box 4]. To confirm that all data has been gathered, checked, and that the patient is ready for surgery. Preoperative orders are written before the scheduled operation [Box 5].



Operative and Procedure note

Immediately after surgery, an operative note must be written documenting type of procedure with main operative findings and estimated blood loss, type of anesthesia, tubes or drains placed, and specimens sent. A full detailed operative summary should follow. [Box 6] shows an ideal short operative note.



Also, a procedure note should be written for all invasive procedures including central lines, chest tubes, percutaneous biopsies, and endoscopies [Box 7].



Postoperative orders and note

After surgery, a new set or orders must be written. One of the postoperative visits during the day or evening of operation should be documented as a postoperative note. [Box 8] and [Box 9] provide ideal postoperative orders and note.



Transfer note and orders

Whenever a patient is transferred from one service to another a note must be written to summarize patient care and ensure proper inter-service communication and decrease possibilities of errors. The transfer note should include a summary of patient's presentations and hospital course. It also summarizes tests, results of consults, and explicitly specifying the diagnosis and treatments. It should state the reason for transfer and specify the accepting service and accepting provider. It should include a detailed medication list and current care and should be dated, timed, and signed. Ideally, a transfer note should be accompanied by a complete transfer orders indicating the transfer service and accepting provider, re-write all patient's orders and plan follow-up.

Discharge plans, summaries, and orders

As a rule, planning for discharge commences on the day of admission. Caring resident should keep touch with patient and the family in regard of discharge planning. He or she should advance diet as appropriate, get any IV, Foley and tubes out, switch antibiotics and other medications to PO form at least 24 h in advance. Discharge summary and prescriptions are written while discharge instructions and follow-up appointments are given [Box 10]. Discharge summaries need to be timely, complete, and accurate. A suitable discharge summary may help prevent adverse events and provide the subsequent treating physician the full medical picture to optimize continuity of patient care. When writing a discharge summary, physicians should ask themselves whether it includes all of the information needed to provide uninterrupted care. As an incomplete discharge summary or one that arrives too late leaves everyone at a disadvantage. Discharge orders must be written in chart and to include: When to discharge, list of medication, other care orders and follow-up appointment. However, do not release till approved by senior resident and consultant.



Sign-outs and hand-offs

Sign-out occurs differently across the various hospitals. In some situations, a designated time and place are arranged, in others, you can sign-out whenever all your work for the day is finished. Sign-out has the potential to be a place where “the ball gets dropped;” don't let this happen to you. The most important aspect of the sign-out is assuring that the overnight person knows what to do in case an issue with your patient occurs overnight. Suggested sign-out information is age, sex, significant PMH, admission date, relevant presenting signs and symptoms, important events of the day and significant tests and findings, working diagnosis, and treatment. It is import to include an on call to do list, anticipated events (list things to watch for and what to do?) and contact information (family member) if pertinent. Use of the mnemonic SAIFIR shown in [Box 11] is very helpfull.



In the event of death

When physicians are called on to pronounce death. Certain steps must be performed: On arrival to the bedside, the patient should be observed for respirations, auscultate for heart sounds, palpate for a pulse, and attempt to elicit a corneal reflex. The exact time of death need to be agreed with the nursing staff. Notify the attending physician and family immediately, even in the middle of the night. Complete a death note in the progress note section of the chart. Consider including the following information: “Called by nursing staff to see patient regarding unresponsiveness. The patient was found to be breathless, pulseless, and without heart sounds, blood pressure, and corneal reflexes. The patient was pronounced dead at (time and date). The patient's physician and family were notified.” Death certificate is an important legal document. It should be filled out completely, accurately and promptly. An assessment of the cause of death should be included. When completing a death certificate, the doctor should print or write clearly, write his/her name in block letters, sign, date, and time the certificate. In addition, record clearly the deceased exact name and demographics as well as accurate time and place of death. It is advisable not to use the following in death certificates: a non-specific term as the modes of dying (e.g., “heart failure” or “cardiopulmonary arrest”), major organ failure such as “congestive heart failure” as an underlying cause of death, terms such a (“asthenia” or “cachexia”), terms that may be misinterpreted as “cerebrovascular accident,” the term “natural cause” and do not use abbreviation or medical symbols such as “#” for fracture.


  Conclusions Top


The practice of medicine involves management of large amounts of information, making the medical record the cornerstone of communication and documentation. Therefore, written communication is an important skill for all physicians and the rule of thumb is “If it is not documented, it does not exist”. Proper documentation is required to record pertinent facts, findings and observations about a patient's health history including past and present illnesses, examinations, tests, treatments and outcomes. Moreover, good documentation describes what information is given to the patient and the patient's response. This includes notes about informed consent, the patient's questions, the physician's answers, and any information given to the patient about next steps or follow up. In addition to eligibility and avoiding using unrecognized abbreviations, particular emphasis must be placed on the five factors: Accuracy, objectiveness, completeness, timeliness and confidentiality. Physicians should only make changes to ensure that the medical record is relevant and accurate. It is important to preserve the original entry and then to write, sign and date any additions or changes. Inadequate notes are open to misinterpretation or are simply unhelpful in providing care to the patient or in demonstrating what took place. Short falling of proper documentation is: Writing illegible, failing to write a note or orders, forgetting to write an immediate operative note on chart, not entering time and date, not naming a diagnosis when ordering a test or treatment or failing to note interaction with family and relatives. Macros and templates may be valuable in improving the completeness and efficiency of documentation.[8] Patient records have been stored in paper form for centuries. Over time they have required a large area of storage leading to notably delayed access, which is limited to one person at a time.[11] Legibility is another major issue and paper-based records are not durable and susceptible to both water and fire.[11]

Electronic Health Records (EHRs) are computerized medical information systems that collect, store and display patient information and are intended to replace existing paper based medical records. Perceived advantages of EHRs can be: Creating legible and organized records, improving access to patient medical information, reducing errors and reducing of papers while forming a data repository for research and quality improvement.[12] Therefore, EHR is having a great potential for improving quality, continuity, safety and efficiency in healthcare. However, the barriers of implementing HER across the world are: high start up cost, need for staff training and continuous technical support, limitations of some systems with lack of customization and concerns for patient privacy and confidentiality.

Authors' contribution

All authors contributed substantially to the conception, drafting, and revision of this manuscript. They all approved its final version.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Compliance with ethical principles

Not applicable.



 
  References Top

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Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;204:533-40.  Back to cited text no. 4
    
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Melvin L, Connolly K, Pitre L, Dore KL, Wasi P. Improving medical students' written communication skills: Design and evaluation of an educational curriculum. Postgrad Med J 2015;91:303-8.  Back to cited text no. 5
    
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Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: II – Most young doctors are bad at giving information. Br Med J (Clin Res Ed) 1986;292:1576-8.  Back to cited text no. 7
    
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Kuhn T, Basch P, Barr M, Yackel T; Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: Executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2015;162:301-3.  Back to cited text no. 8
    
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Guidelines for Medical Record and Clinical Documentation WHO-SEARO Coding Workshop; September 2007. https://jhmvhi.jhu.eduLast visit. [Last accessed on 2018 Nov 15].  Back to cited text no. 9
    
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The Protective Canadian medical Protective Association. Why Good Documentation Matters, originally published March 2011/Revised October 2016. P1101-6-E. Available from: https://www.cmpa-acpm.ca. Last accessed 2018 Nov 15].  Back to cited text no. 10
    
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Evans RS. Electronic Health Records: Then, Now, and in the Future. Yearb Med Inform. 2016 May 20;Suppl 1:S48-61.  Back to cited text no. 11
    
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Ayatollahi H, Mirani N, Haghani H. Electronic health records: What are the most important barriers? Perspect Health Inf Manag. 2014 Oct 1;11:1c. eCollection 2014.  Back to cited text no. 12
    



 
 
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