Patient Care With Clinical Documentation
Friday, April 10th, 2009
Clinical documentation is the recording of various details about a patient’s clinical history. Well maintained clinical documentation should include proper assessment of the patient, all identified problems, the likely outcomes, the patient’s response to treatment, the care delivered, all decision-making procedures undertaken, patient’s condition during discharge and plans for ongoing care, if any. All these are recorded and stored in a manner that would be helpful not only for the better treatment of the patients, but also as a study source for other clinicians looking for verifiable content before carrying out similar procedures on other patients.
A clinical documentation improvement program is all about keeping the records of the patient on par with the concerned health body’s rules and regulations. Although nurses actually help in maintaining most of the records, clinicians and physicians play an important role. They give the right data that needs to be included in the documentation procedure. With the advancement in the field of technology, many health bodies are setting their rules and regulations to a higher standard. Most clinics have started focussing more on providing quality care. All entries made in the clinical documentation need to be signed and dated by the clinician involved. A person cannot in any manner cancel or delete an entry that is already made. It thus calls for precise information to be present. Permanent ink is used and the writing needs to be legible and clear.
All data that is collected and recorded in the clinical documentation is of utmost importance as it could be used as reference in future medical procedures or by other health professionals. Recording all this data effectively also helps the patient. The complete clinical procedures of the patient are recorded in a precise and efficient manner, thus enabling the clinicians and other healthcare professionals to make a thorough assessment of what needs to be done further. Since it contains details of the patient’s entire medical history along with the diagnosis, the treatment planned, the manner in which the treatment was carried out, the outcome of these treatments and the response of the patient and any further treatment needed, the documentation gives tremendous support to any information the patient may require. All information is stored in a well-formatted, accurate manner by experts, as facts.
There are numerous benefits of clinical documentation to both the patients and health professionals. The concerned patient will have a detailed record of their treatment while other patients can look up to this documentation as a verifiable reference. This also helps other health professionals to diagnose wisely while treating their patients.
By: Tom Billmore
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