How can you effectively document patient care when working with physicians?

Recent CMS rules have changed the focus of documentation. We need to utilize these changes in order to document more appropriately. The new rules have de-emphasized the history and physical part, and have emphasized the medical decision making. Therefore, using whatever strategies are available in the electronic medical record, we need to clearly document our thinking process, our clinical reasoning, and the plan to manage the disease processes we believe The patient is suffering from. It is so essential.

Documentation of vein disease for insurance coverage typically requires thorough and comprehensive medical records to support your claim. Here are some key necessities: Medical Diagnosis: Ensure that you have a clear and formal diagnosis of your vein disease from a licensed healthcare provider. This diagnosis should include the specific type of vein disease, its severity, and any related complications. Treatment Plan: Document the recommended treatment plan, including medications, procedures, surgeries, or lifestyle changes prescribed by your healthcare provider. This should include details about the frequency and duration of treatment. Imaging and Tests: Include the results of relevant diagnostic tests, such as ultrasound scans and IVUS.

Use technology to automate the process. Anodyne Clinical has created an application called FreeTime (FreeTimeMed.com) that uses patient responses and EMR data to comprehensively document the patient encounter.

After, a career of 38 years in healthcare working directly and indirectly with physicians as a direct care clinician and as a hospital executive, I would agree with the need for precise language. Utilizing objective, evidenced-based conclusions to inform the physician about your clinical evaluation is how we were trained to communicate effectively. However, despite, the rules and standards which point us toward objective measures, the “patient” is still a person and deserves both our scientific and our humanistic perspective.

Aristotle, 2300 years ago suggested ABC of communication (he called it Rhetoric) A: Audience, B: Brevity, C: Clarity. The notes will be read by Respiratory, Nutrition, Physical therapy people etc besides nurses, interns, medical students and may be attorneys, who believe if not documented didn’t happen. Avoid abbreviations. Emphasize “why” (basis/foundation) of your decision making. Document in nutshell if you talked to someone including family members, merely saying explained pro and cons is not enough, document salient features of your conversation. Stick to Aristotle’s ABC in daily life.

Effectively documenting patient care when collaborating with physicians involves clear and concise language, standardized formats, timely and objective documentation of relevant details, close collaboration, highlighting critical changes, adherence to legal and ethical guidelines, utilizing EHRs, recording communications, maintaining organization, continuous education, and prioritizing patient safety and institutional policies.

Implement standardized templates for common medical encounters. Templates can help ensure consistency, completeness, and adherence to best practices in documentation. Clearly document the physician's decision-making process, including the rationale behind diagnostic and treatment choices. This helps provide context for future care and supports accountability.

How many of us have a tool in which un-resolved needs, symptoms, patient complaints, and new symptoms each have a separate thread? This would put each concern into a thread. Perhaps it is VITAL SIGNS, PRESSURE ULCER, FLUID INTAKE, CALORIC NEEDS AND DIETARY INTAKE (and so forth). Does anyone categorize notes by body systems? I’m curious about the formats being used. Thank you for any replies

Keep in mind, this is the standards of your peers. If you veer off from the standards of care, you must have empirical data to support your clinical decision making. While you may not agree with the standards, you must respect them. It also keeps you from second guessing yourself when directing the care of the patient.

The standards and guidelines set by our organization and profession are meant to be a tool for guidance.Not every specialty falls into the standard category.The standards of operating procedures (SOP) for that specialty override the hospital standard but stay within the guidelines set up by the accrediting body ie joint commission or a specialty ie FACT and CLIA.These all have specific standards.The SOP is written bases on evidence findings and requirements set by the accrediting body.Once appropriate guidelines are in place the nurse can effectively document to their standard of care. SBAR and SOAP are no longer used.IPASS is utilized in a group report vs face to face.This allows the RN to be aware of all of the patients current status.

Advocate for interoperability between different healthcare systems and EHRs to facilitate seamless information exchange among healthcare providers.

I have personally witnessed physicians from different departments disagree and go back and forth with each other about the care plan for a shared patient. Unfortunately, in some of those instances, the arguments were made and written in the patient’s chart. Clearly, best practices regarding documentation were not upheld. Health care is multifaceted and would involve multidisciplinary teams. As such, disagreements regarding care are bound to occur, but those should take place in grand ward rounds, multidisciplinary team (MDT) meetings, etc., and not the patient’s chart.

Having open communication with all my physicians help the practice to run smoothly. We keep in touch with all our referring doctors.

Health records aren't appropriate for interpersonal quarrels. Leave your personal disputes out of it. Be polite, to the point and if you share your train of thought, others can learn too.

Respectful communication is so important. It shows respect for all parties involved and also willingness to want to hear to one another. Important to remember the overall goal is to care for patients, so important to place their best interest as the priority.

Encourage physicians to document patient encounters promptly. Timely documentation reduces the risk of information gaps, improves accuracy, and enhances the overall quality of patient records.

Document in real-time: Try to document patient care as soon as possible after providing the treatment or conducting an assessment. This will help ensure accuracy and prevent any potential gaps or omissions in the documentation. Review and proofread before finalizing your documentation, review it carefully to check for any errors or inconsistencies. Typos or inaccuracies can hinder the understanding of the patient's condition and may lead to potential medical errors.

Keep in mind, everyone on the healthcare team is responsible!! Never assume a patient will repeat information to the provider- you may have key information that will impact the care plan.

It is also worth noting that timely reviews and updates of clinical documentation ensures that patient charts are signed off and closed early. In some instances unsigned or late documentation results in unbillable patient charts. Under no circumstances should a patient’s chart be left opened, unsigned, or undocumented for an extended period of time.

Documentation is a critical piece of patient care delivery. It is also a communication tool with all members of the healthcare team. Your documentation and practice of what you document and include in notes may change over time. As time goes on, be sure to review updates policies, procedures and guidelines to ensure that the details provided and documentation included are complete have all important information.

As a legal nurse consultant, I review medical records for attorney clients nationwide. It has made me a more detailed writer and intentional about what I include in my notes at my clinical job. There is a quote that says "Chart/Document as if your nursing note will be read aloud at a deposition". I see the importance and value in this saying.

1. Poor documentation is a cause for concern as it affects quality of care, compliance and billing processes. 2. If it was not documented, then it was not done!

Guidelines around clinical documentation change from time to time. It can be beneficial to work closely with your Clinical Documentation department to stay up on the latest guidelines.

1. Include any refusals of the patient, document if the patient refused any treatment before,& the reason for refusal. 2. Include nursing interventions, document what’s done to the patient, why it’s done & what was the outcome. 3. Take notes in real time ASP, after the patient encounters; while the information still fresh in mind, avoid delays or gaps. 4. Include follow up care (document any instructions or referrals given to the patients for their ongoing care . 5. Document symptoms & treatments, document patient’s chief complaint, history of present illness, past medical history,family history, social history,review of symptoms,physical examination,laboratory & imaging studies diagnosis,treatment plan, medications & health education.

As the former administrative director of a multi-specialty medical group I worked with multiple physicians. Regardless of the specialty, one commonality was intermittent patient chart reviews. As a result of some of those harried events, I encouraged the physicians in our practice to document with a futuristic mindset, such that when, not if, somebody else must review that chart one or two weeks, or even years later, they would be able to understand what you did and why that was the best option at that time, given your situation, resources and standard of practice.