The art and science of clinical record keeping deserves – but does not often get – as much attention as delivering quality healthcare. Yet proper record keeping – initial creation of the record, ongoing entries and maintenance, and retention – protects providers in a number of ways including:
How can providers make the record keeping process simpler and more straightforward? Here are a few tips to help providers and staff.
Adopt a System
There are many styles of chart notes to choose from that can be effective. Narrative notes in SOAP format are the standard. Whether in electronic or written form, there are a variety of ways to simplify clinical record keeping, including check-box formats, pre-printed forms, computer-generated notes, and barcode SOAP notes. However, some of these shortcuts produce “canned” notes that contain little clinical content. In whatever method chosen, be sure to leave room to completely document the clinical thought process for later reference.
If the office is using an Electronic Health Record (EHR) system, take the time to become very familiar with the standard functions so that it is easy to use during daily patient care. If the office is using paper charts and records, know where to look in every chart for the same data.
Check the Clinical News blog every Thursday through July for more in our Best Practices series