You’re probably not thinking about the stuff you wrote about today’s middling-good group session as something that could be important when an insurance company reviews the case.

A survey questionnaire for customer satisfaction with checkboxesImproving Clinical Documentation

Here’s what many of us in the field fail to realize: Documentation is communication.

Right, that dry routine stuff we pump out on deadline in response to somebody else’s annoying requirement is in reality a form of interpersonal communication– but with unknown persons, and at some indefinite future point in time.

And that’s a challenge, maybe the biggest of all.

You know that a note you write may be read by a records reviewer compiling data for quality improvement. You may not think in terms of who else might read it when they’re doing chart review for an annual survey or audit, or during a visit from a licensing or accreditation surveyor. You’re probably not thinking about the stuff you wrote about today’s middling-good group session as something that could be important when an insurance company reviews the case.

And I’m almost positive you don’t think of it in terms of a possible lawsuit down the road, where you could be deposed or even called to the stand to give testimony in front of a jury.

But, sadly, that note could be all those things.

Some super-simple rules for writing a good note:

Stay with the facts. Focus more on accurate description than subjective interpretation. That’s true even on assessments, where unnecessary comments can create problems. No need to be like those celebs who have to apologize for some ill-timed joke on Twitter.

Provide enough information, but not more. I believe it was Calvin Coolidge who remarked that he never got in trouble for something he didn’t say. Once you’ve covered the essentials, consider stopping.

Don’t wander off-subject. You may have many interesting thoughts circling in your head, but perhaps they don’t add anything to this particular note.

Don’t allow the format to overwhelm the message. Many of us have worked in programs where we had to use the SOAP or DAP format for progress notes. That’s fine but it can sometimes make for difficult reading if the writer isn’t all that skilled in using that format.

Here’s an actual SOAP note I found in an inpatient record, from a member of the nursing staff.

S(ubjective): “I feel like I may want to hurt myself.”

O(bjective): Patient attended group, played volleyball, went to Art Therapy. Took medications on time.

A(ssessment): Patient doing well in milieu but having some thoughts of self-harm.

P(lan): Continue to encourage progress, continue monitoring for suicidal ideation.

Imagine you’re another therapist who happens to read that note. What do you make of it?

First: Is this patient becoming suicidal? If not, as her behavior seems to suggest, then why is she talking about self-harm? Is it an empty threat that shouldn’t be reinforced, or something more serious on the rise? Hard to tell from the note. And yet, it’s important. Suppose the patient does act out in the next few days– will it look like the staff just blew the assessment?

Another consideration: Does this staff member’s observations agree with, or perhaps conflict with, other notes that are in the chart? Progress notes are supposed to “tell the story” of a treatment course. If that story contains a number of inconsistencies, won’t the reader just be confused?

When it comes to clinical documentation in a legal record, we do not want to confuse the reader.

This is an example of a case where problems with the recommended format interfere with the quality of the documentation. It isn’t that the SOAP format is bad; it’s that the person making the note wasn’t able to make effective use of it.

Can we correct this? Yes. See the next installment.


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