Unexpected Benefit to Quality Documentation: Improved Communication Between Providers

In the world of mental health, it is not uncommon for a client to be struggling with multiple ailments at the same time.

These are just a few examples of how mental health clients might require support from collaborating fields in order to fully address the root causes of their concerns.

As mental health professionals, it is important that we are providing quality person centered care, and a large part of this is collaborating with other professionals as needed. Effective communication between healthcare providers is essential to ensure the best possible outcomes for patients. However, with so many providers often involved in a patient’s care, it can be challenging to maintain clear and concise communication.

In this article we will discuss the importance of having strong clinical documentation that accurately and concisely reflects the clients care as to optimize intercicipline collaboration.

Importance of Clinical Documentation

Highlights Symptomatology

When writing any type of clinical documentation it is important to feature the client’s changing symptomatology as a way to document medical necessity. Reporting on original symptoms (ie. fatigue, restlessness, and appetite changes) helps practitioners develop a clear diagnosis and treatment plan. As treatment continues, reporting how these symptoms improve or regress over time will help to highlight the effectiveness (or ineffectiveness) of treatment.

Why does all of this matter?

First, the practical reason for this is that insurance wants to know what symptomatology is presenting for reimbursement reason. Not the best reason but it it is the truth. Insurance wants to be sure that they you are providing a medical necessary service and the best way to “prove” this is by highlighting symptomatology.

Another not fun but important reason is for the legal protection of malpractice. If for whatever reason (knock on wood) you end up in a malpractice or other legal situation, your documentation is your supporting evidence of why you did (or didn’t) do what you did (more below). Remember, if it isn’t documented it didn’t happen.

Lastly, and most importantly, high quality documentation improved patient outcomes to treatment. Let me explain…

Improves Patient Outcomes

Strong clinical documentation can help healthcare providers ensure that patients receive appropriate and timely care, which can lead to better health outcomes. You may have heard the term, “what we measure matters.” This is why we keep budgets to monitor our spending, or wear fitness trackers to monitor our sleep and activity. By monitoring (and keeping track of) progress and setbacks within the clinical documentation, we as clinicians can have a better pulse on what is working for our clients so we know where to step on the gas to help more.

Aids In Legal Defense:

As I mentioned earlier, poorly documented patient care can have serious legal implications for healthcare providers, including malpractice suits and loss of license. Strong clinical documentation is crucial for protecting yourself legally as a therapist. Not only does it demonstrate the what and the why of your work with clients, but it also showcases your decision-making process.

Collaborating with other healthcare professionals and involving clients in decisions can be highlighted through proper documentation. This not only shows that you did not make unilateral decisions but also proves your intention to provide the best possible care for your client. Therefore, having strong clinical documentation is an essential aspect of ethical practice and ensures that clients receive the highest quality of care.

If you have trouble with documentation and struggle to produce high-quality documents, I highly recommend taking my course. It teaches efficient documentation techniques using templates that have been transformative for me and my practice. You can learn more about this course by clicking here.

Communication Challenges in Healthcare

Communication challenges in healthcare are increasingly becoming more complex due to the existence of multiple providers and facilities, as well as differing note taking systems. As healthcare providers work with a variety of specialists across disciplines, sharing information becomes difficult when each provider uses different terminology and methods to document patient data.

Additionally, patients often receive care at multiple facilities, making it challenging for providers to access complete records. This disjointed approach can lead to miscommunication or inaccurate diagnoses and treatment plans, emphasizing the need for a centralized communication system that can bridge the divide between providers and facilities.

How Clinical Documentation Improves Communication

Promotes Collaboration

Clinical documentation helps foster collaboration among different healthcare providers who may be treating the same patient. When clinicians have access to up-to-date and accurate patient information, they can make more informed decisions about the patient’s treatment plan. With improved communication between providers, patients receive more comprehensive care as their health needs are addressed from various angles.

For instance, if a primary care physician and a trauma specialist communicate effectively through quality clinical documentation, they can work together to create a more effective treatment plan that addresses both the immediate anxiety symptoms with medication and address the root cause with talk therapy to eradicate the problem from reoccurring or worsening. Ultimately, this results in improved outcomes for patients and a higher standard of care.

Can Reduce Fragmented Communication & Misunderstandings

Taking a multidisciplinary approach helps other practitioners, such as primary care physicians, speech therapists, occupational therapists, surgeons, psychiatrists, or any other professional, understand what is happening in the therapy room. With multiple treatment providers however, the risk for miscommunication rises. By having a common document to refer back to, healthcare teams can avoid relying solely on word of mouth conversations that may be prone to errors or forgetfulness.

Successful documentation requires skill as it is both an art and a science. It is important to provide enough detail to give a clear picture of the session, client’s struggles and symptoms WHILE still maintaining client privacy. By focusing on the facts of treatment (ie. symptoms and interventions) vs. subjective interpretations, you reduce the risks of multidisciplinary interpretation errors that can arise from subjective opinions or personal biases. Ultimately, prioritizing strong clinical documentation can help ensure that patient care is efficient, effective, and accurate.

Better Decision-Making

Like many things in life, knowing the facts of a situation can significantly aid in the decision making process. When communicating with other healthcare providers, it’s important not to neglect important details such as the symptoms and duration of the patient’s condition. This can be done using objective measurements and data to enhance your communication. Sharing this information with your colleagues can greatly aid in their understanding and treatment of the patient. This transparency of clinical evidence allows for better collaboration among care team members, leading to more informed decision-making and improved patient outcomes.

The structure of the document can also aid in decision making by making the notes accessible and reader friendly. By recording and organizing patient information in a standardized format ( I use templates for this), clinical documentation provides a central location to look at all the facts on both a macro and micro level. You can zoom in and look at the nitty gritty details of one day or zoom out and see the big picture of someone’s treatment as a whole. Plus, having everything in one place makes decision making easier and more accurate.

Clinical documentation may not be the most exciting thing in the world, but it definitely plays a huge role in providing quality care!

Best Practices for Effective Communication

Use Clear and Concise Language

Effective clinical documentation should use clear and concise language that can be easily understood by other healthcare providers. Remember this is a progress note, not a poem. Keep the multiple flowery descriptors to your creative writing projects and focus on using the best 1-2 adjectives to describe what is happening.

Use Bullet Points and Lists

Consider using bullet points and/or lists to concisely yet effectively transfer your message. Bullet points are a great way to make sure all the information is available in an easily skim-able package (perfect for busy providers). The goal is for readers to understand the information within a minute or two. Using a lists and templates (more on templates in a moment) can be helpful in directing readers to specific sections, such as symptoms, which may be more relevant to them than interventions.

Providers are typically more concerned with symptomatology, barriers, and effectiveness, while the process of how the information is documented falls under your domain. Clear and easily accessible documentation can greatly facilitate communication among healthcare providers.

Have a Standardized Form or Template

Regardless of your writing style, I recommend using and sticking to some form of standardized format or template to keep your notes in order,. This is helpful for you writing the note, and even more helpful for someone reading it as they can easily jump to the section they are in need of. If you are collaborating with a colleague on a shared patient, there is a good chance they will be reading multiple notes written by you. By using a standardized format, in time they will be able to know where exactly to look in your note for the information that is helpful for them, ultimately saving them time, frustration, and energy.

Avoid Clinical Jargon

If you prefer using a long form narrative style, use terminology that is easily understandable for all parties involved, including the patient who may be reading it. Avoid using too much medical jargon as it cannot be assumed that everyone has the same level of knowledge in the field. The goal should be to provide concise yet comprehensive information.

Now that being said, it is okay (and important) to use diagnosis terms and descriptors that are easily recognizable. For example, if a client is clinically depressed be sure to use the word “depression” and back it up with symptoms. Stating the client is “sad” will not accurately describe this diagnosis to to point of medical necessity as every human is and will be sad at some point in life. Be sure that the terminology you do use is accurate to the situation at hand.

Focus on The Facts Not Opinions

Clinical documentation should provide accurate information about the patient’s medical history, ongoing treatments, test results, and any other relevant details. More specifically, focus on the facts of a session and not your opinions. If there is a clinical observation you want to incorporate be sure that it is clearly stated that this is YOUR thought and not a statement from the client. Other practitioners might interpret the facts differently (one of the primary benefits of collaborating is to see different viewpoints) and you do not want to skew this information by hiding the facts in your opinions.

Conclusion: Effective communication improves healthcare outcomes

In conclusion, quality clinical documentation is essential in improving communication between healthcare providers. It not only helps in the better coordination of care but also ensures accurate and timely diagnosis, treatment, and prevention of diseases. With improved communication, patients can receive better care that leads to positive outcomes such as reduced hospital readmissions, improved patient satisfaction, and decreased healthcare costs. Therefore, it is important for healthcare providers to prioritize quality documentation practices to enhance patient outcomes. Let us work together towards achieving better patient care through effective communication and documentation.

If documenting is a struggle for you and you find it difficult to create quality documentation, I strongly encourage you to check out the course I offer entitled Mastering Clinical Documentation With Speed and Efficiency. It teaches how to document efficiently using templates, which has changed my world. I hope it will be helpful for you too.