What are the best practices for ensuring complete, accurate, and up-to-date medical documentation?

1 Know the purpose

Different types of medical documentation serve different purposes and audiences. For example, a progress note is a concise summary of the patient's condition, treatment, and plan for a specific date, while a discharge summary is a comprehensive overview of the patient's hospital course, outcomes, and follow-up instructions. Knowing the purpose of each document will help you decide what information to include, how to organize it, and how to format it.

2 Follow the standards

Medical documentation should follow the standards and guidelines of your institution, specialty, and regulatory bodies. These may vary depending on the setting, specialty, and type of document, but they generally include elements such as patient identification, date and time, author identification, signature, and authentication. Following the standards will ensure that your documentation is consistent, compliant, and credible.

3 Use clear and precise language

Medical documentation should use clear and precise language that conveys the facts and avoids ambiguity, jargon, and slang. You should use medical terminology correctly and consistently, and define any acronyms or abbreviations that may not be familiar to the reader. You should also use proper grammar, spelling, and punctuation, and avoid unnecessary modifiers, qualifiers, and opinions.

4 Be objective and factual

Medical documentation should be objective and factual, based on your observations, assessments, interventions, and outcomes. You should avoid making assumptions, inferences, or judgments that are not supported by evidence. You should also document any deviations from the standard of care, such as errors, adverse events, or patient non-compliance, and explain the rationale and actions taken.

5 Update and review regularly

Medical documentation should be updated and reviewed regularly to reflect the current status and progress of the patient. You should document as soon as possible after providing care or receiving information, and avoid using vague terms such as "later" or "soon". You should also review your documentation for accuracy, completeness, and consistency, and make any corrections or additions as needed. You should never alter or delete existing documentation, but rather add an addendum or a late entry with the correct date and time.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?