Documenting information

Clinical documentation is information that is recorded about a person’s care. The primary purpose of clinical documentation is to facilitate safe, high-quality and continuous care.

Clinical documents can take on a number of forms and be paper-based, electronic or a mix of both. These documents include treatment and observation notes, care plans, correspondence, test results, x-rays, clinical photos, medication charts, checklists, operation reports, transfer forms, clinical summaries and information from specialists, community workers or general practitioners.

The healthcare record

The primary place for clinical information to be documented is in the healthcare record. The healthcare record can be made up of a number of different clinical documents, and is the place in which all relevant clinical information about a patient is stored. This includes information about the patient’s medical and social history, about the progress and health outcomes of each intervention or interaction, and information from families and carers.

Documentation needs to be an accurate reflection of clinical events and clinician decision making for classification (coding) purposes as well as a method of communication to facilitate continuity of care. Clinical coding is a health administration function that abstracts clinical information from the healthcare record for the assignment of standardised ICD-10-AM (International Statistical Classification of Diseases and Related Health Problems) and ACHI (Australian Classification of Health Intervention) codes. 

Accurate documentation of diagnoses and patient care interventions ensures correct translation of data and appropriate coding. Clinical coding data is used for health resource planning and allocation, epidemiological studies, clinical benchmarking, and financial reimbursement determined on casemix based payments.

Other documents that support safe transitions of care

Transitions of care are high-risk situations for patient safety. It can be common for patients to experience multiple transitions of care when they go through the health system. 

Documentation is a way in which the reliability of information is maintained, and shared between different treating clinicians and with the patient, their family or carer. High-quality documentation of clinical information is therefore essential to ensure that clinicians have available all of the information they need to safely transfer the care of a patient.

Clinical documents that support safe transitions include care plans, transfer, referral and request forms, event summaries, short stay summaries, discharge summaries and shared health summaries. These documents have a specific purpose and aim to facilitate the continuity of care.

Figure 1 is an example of how the healthcare record is an important source of information for clinicians, and how information available in the healthcare record is used to inform and facilitate safe transitions of care.

How information is transferred, communicated and documented for a transition will depend on the situation and purpose of that transition. Clinicians transferring care will need to exercise clinical judgement and synthesise information to ensure information transferred is fit for purpose, accurate, current and takes into account the specific needs of the patient.

Figure 1: Ensuring information is available to clinicians is essential to facilitate safe and continuous care

Documentation of information, which is accurate, current, relevant, available and accessible, supports clinicians to deliver safe, high-quality care by ensuring they have correct information to:

• Make safe clinical decisions 
• Effectively communicate across transitions with other healthcare providers and across multidisciplinary teams
• Maintain effective continuity of care 
• Effectively communicate and partner with patients.

Increasingly, the delivery of health care involves multidisciplinary teams. To ensure safe care, complete and accurate health information needs to be available and shared in a timely way to clinicians responsible for care, and to patients, families and carers. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. This lack of communication can lead to a loss of information and result in a number of unplanned or poor outcomes and different types of adverse events.

Evidence shows that poor documentation of information can lead to:

• Higher readmission rates to hospital
• Failure to follow-up after hospital discharge
• Increased costs related to inadequate or reduced care coordination
• Lack of referrals to community service providers
• Increased presentation of emergency departments and increased lengths of hospital stay
• Sub-optimal management of patients’ conditions, inadequate assessment of functional state and inadequate detection of preventable complications in intensive care units
• Lack of availability of important diagnostic results
• Medication errors, including delays and omissions of antibiotics, missed medications and dose errors, and emergency medications being ceased accidently or missed
• Patient deterioration requiring medical emergency team calls and patient falls. 

Documentation of information can mitigate some of these safety and quality risks, by ensuring that essential information about a person’s care is available to clinicians, and support effective communication. 

Good clinical documentation and high-quality healthcare records also enable clinicians to meet their legal requirements, and for accurate clinical coding to be accomplished.

Regardless of the medium (paper or digital), high-quality documentation should follow the same guiding principles as outlined in Table 1.

Table 1: Guiding principles for high-quality documentation.

Specific consideration should be given when documenting information for patients with complex and chronic healthcare needs, including:

• Older patients
• Hospitalised children
• People with mental illness
• Patients with multiple comorbidities
• Patients admitted to intensive care
• Aboriginal and Torres Strait Islander patients
• Patients moving along the perioperative pathway
• Palliative care patients.

These patients are a high risk group for patient safety and the complexity and fluidity of information generated for these patients means that documenting up to date, accurate and complete information can be challenging. It is important to consider if there is any additional information that needs to be documented, and ensure that information is tailored to a patient’s specific care needs. 
 

Useful resources that may help you improve documentation of clinical information in your organisation include: