| One-Minute Clinician

Documentation: A Legacy of Patient Care?

Documentation is a many-headed beast:

  • It started out as a way to keep track of what we’ve done, to create a record that would be a legacy to patient care
  • It has transmogrified into a tool for billing, a risk management function
  • It tries to document with other professionals who are caring for the patient all that you were thinking, all that you had to deal with in the care of that patient
  • As a result, the demands on documentation have increased exponentially
  • It puts additional pressures on the practitioner to really try and capture what it is that they’ve been providing in terms of care

People refer to the adage that if it wasn’t documented, it didn’t happen:

  • We all know that that’s an unreasonable standard and impossible to accomplish
  • What you’re trying to do as best possible is document the essence of your care, the thinking that you were engaging in, and why you did what you did at any particular time
  • No note should have to stand alone
  • It is the record as a whole that documents the episode of care for that patient, which should tell a story that makes sense to you and to anyone else who’s reviewing that document