Questions and Tips to Improve Your Documentation!

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Improve Your Documentation!

The importance of documentation cannot be overemphasized. In this post, I wanted to share some questions and tips to improve your documentation. As nurse case managers, we learned about documentation during our training, but with technology taking over healthcare, our documentation is more important than ever.

Take some time to think about how you document. Is it clear? Does it help the healthcare team coordinate care and ensure streamlined communication? Could a colleague pick up your cases if you had to take time off?  Here are some points to review and see how you can improve your documentation.

* Does your documentation assist in clinical management, care coordination, progression of care, and improving communication?
* Does your documentation justify interventions and expenses?
* Would your documentation defend your work if you were called out on something you did or did not do?
* Is your documentation objective?
* Does your documentation include facts?
* Are you comfortable with having your documentation read by the public?
* Does your documentation avoid bias and personal opinions?
* When do you document? Is it timely? Studies show the best time to document is during or right after the encounter when things are fresh in your mind.

What should be documented depends on the setting in which you work. Follow your policies and procedures regarding documentation. Here are some things you should consider documenting as part of your role as a case manager.

* Your assessment
* Your observations
* Monitoring your clients’ activities and changes that you suggest/make
* Evaluation findings
* Interventions
* Communication with the healthcare team
* Progress with current treatments/or setbacks
* Modifications to the case management plan, including rationale
* Outcomes and your part in achieving those outcomes
* Discharge planning activities, challenges, and what you did to address them
* Medical stability of your patient within 24 hours of hospital discharge
* Plan of care, including patient/family involvement and agreement to the plan
* Patient/family education
* Evidence of continuation of care after discharge from inpatient setting
* Who a patient/family should follow up if they have questions or issues
* Discussions with the adjustors, doctors, employers, vendors, and other healthcare team members, including the patient and the family, should be documented.
* Advance directive preparation

Lastly, ensure your documentation illustrates your work. Do not allow anyone to add, change, or put information in your documentation that you disagree with or did not do.

I hope this article spurs you to look at your documentation critically and make changes where needed!

Anne Llewellyn MS, BHSA, RN-BC, CCM, CRRN CMF, CMGT-BCBio: Anne Llewellyn, MS, BHSA, RN, CRRN, CMGT-BC, BCPA, FCM is a registered nurse with 40 + years of clinical experience. She is also a digital journalist writing for various e-newsletters on topics of digital health, workers’ compensation, case management, and the importance of educating people to be their own best healthcare advocates.

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