All health service personnel who deliver or are involved in delivering frontline health services are required to document their work. This is must be at the core of all health care. Follow-up topics: The Documentation Dilemma: When Too Much Meets Too Little and Documentation 2.0.

Table of Contents

• What does documentation mean? 
• Documentation in health services
• Standards
• The burdens and challenges
• Deficient documentation
• Fostering good documentation
• Take away summary

What does documentation mean?

Documentation as a word has several meanings depending on the context in which it is used. Here are a few common interpretations:

1. Record keeping: In a general sense, documentation often refers to the act of keeping detailed records. These records can be about any number of things, such as financial transactions, business operations, or patient health information in a medical setting.
2. Proof or evidence: Documentation can also refer to materials that provide evidence or proof of something. For example, you might provide documentation to prove your identity, such as a passport or driver’s license.
3. Instructions: In some contexts, documentation refers to written instructions or explanations. For example, in software development, documentation often refers to written material that explains how to use or understand the software.
4. Process recording: In project management and other fields, documentation can refer to the process of recording all the steps taken in a project, including decisions made, changes in scope, and lessons learned.
5. Legal compliance: In legal and regulatory contexts, documentation often refers to the process of keeping records that demonstrate compliance with laws, regulations, or standards.

Documentation in health services

Of the above, record keeping is the most salient context in health service delivery. However, some of legal compliance, proof of evidence and instructions will also be relevant.

Why document at all? Good health service documentation is crucial for ensuring effective patient care, communication among healthcare providers, legal protection, quality improvement, and research. Here are the main issues:

1. Continuity of care: Detailed and accurate documentation allows for continuity of care. Different healthcare providers can review the records and understand the patient’s medical history, current condition, and treatment plan, which is especially important when multiple providers are involved in a patient’s care.
2. Communication among healthcare providers: Documentation facilitates communication among different healthcare providers. It allows doctors, nurses, and other healthcare professionals to share information about a patient’s health and treatment.
3. Legal and professional requirement: Documentation is a legal and professional requirement. It provides a record of the care that was provided, decisions that were made, and the patient’s consent to treatment. This can be important in case of any legal proceedings or professional review.
4. Quality assurance and improvement: Documentation can be used for quality assurance and improvement. By reviewing records, healthcare providers can identify areas where care could be improved, track the effectiveness of certain treatments, and monitor patient outcomes.
5. Research and public health: Anonymised patient data can be used for research purposes and to monitor public health trends. This can lead to better understanding of diseases and more effective treatments.
6. Billing and reimbursement: Documentation is often required for billing and reimbursement purposes. It provides a record of the services that were provided to a patient, which can then be used to bill the patient or their insurance company.
7. Patient safety: Good documentation can help prevent medical errors by providing clear and accurate information about a patient’s allergies, previous adverse reactions, current medications, and other important health information.

Standards

The following are well accepted by most regulatory bodies and ethical guidance:

1. Accuracy: Clinical records should be accurate and factual. They should not contain any speculative content or personal opinions unless they are clearly marked as such. Inferences and assumptions ought never to be made into statements of fact. Probabilistic statements should be explained fully.
2. Comprehensiveness: Records should be comprehensive and include all relevant clinical findings, decisions made, information given to patients, and any drugs prescribed or other investigations or treatments. Whilst the General Medical Council removed the word ‘comprehensive’ from its latest version of Good Medical Practice, comprehensiveness is still expected of most health records.
3. Timeliness: Records should be made at the same time as the events they record or as soon as possible afterwards.
4. Clarity: Records should be clear, legible and in a format that can be understood by others. If abbreviations are used, they should be commonly understood.
5. Confidentiality: Patient information should be kept confidential and secure. It should only be shared with those involved in the care of the patient and only with the patient’s consent, unless there are overriding considerations such as risk to others.
6. Retention: Records should be kept for a period of time in accordance with legal and professional requirements. In the UK, this is typically for a minimum of 10 years after the conclusion of treatment or death.
7. Access: Patients should have access to their own records in accordance with the law and professional guidance.
8. Data Protection: Doctors should comply with data protection legislation and any other relevant laws.

The burdens and challenges

While proper documentation is crucial in health services, it does come with its own set of challenges and burdens. Here are some:

1. Time consumption: Proper documentation can be time-consuming. Healthcare providers often need to spend significant amounts of time recording detailed information about each patient encounter. Time impacts can lead to cutting corners on documentation itself, and spending less time than needed with patients.
2. Complexity: The requirements for medical documentation can be complex and may vary depending on the specific situation, the type of healthcare provider, and the jurisdiction. Keeping up with these requirements can be challenging.
3. Training: Healthcare providers need to be trained in proper documentation practices. This training can be costly and time-consuming, and it needs to be updated regularly to keep pace with changes in regulations and best practices.
4. Technology challenges: Electronic health records (EHRs) have become the norm in many healthcare settings, but they come with their own challenges. These can include issues with usability, system errors, and difficulties in integrating different systems.
5. Privacy and security: Protecting patient information is a major concern in health services. Documentation needs to be stored and transmitted securely to prevent breaches of patient privacy.
6. Burnout: The administrative burden of documentation can contribute to healthcare provider burnout. This is a significant concern in the healthcare industry and can lead to decreased provider satisfaction and increased turnover.
7. Cost: The systems and processes required for proper documentation can be costly. This includes the cost of EHR systems, training, and the time spent by healthcare providers on documentation.

Deficient documentation

There are several common poor practices associated with health service documentation. These can compromise patient care, lead to legal issues, and create other problems. Here are some examples:

1. False and fake documentation: No one knows how much false documentation is made among health service practitioners. Does ‘No TLNWL’ mean that the assessor of a patient’s mental state actually ascertained that the patient had no ‘thoughts of life worth living‘? Or if it is documented ‘no suicidal ideation expressed’ – what does that mean? Was it actually explored? It would be a difficult study to undertake, whether what was documented was actually ‘done’. Such a study would probably involve covert recording of consultations and comparing what was said to what was recorded. It is doubtful that anyone would approve such a study in real-world health service practice. However, it could be undertaken in a simulated setting – but such a study would find it difficult to replicate the pressures of real-world practice.
2. Incomplete or inaccurate documentation: This is one of the most common issues. It is crucial that health records are complete and accurate to ensure continuity and quality of care. Missing or incorrect information can lead to medical errors.
3. Illegible handwriting: While many health records are now electronic, some are still handwritten. Illegible handwriting can lead to misunderstandings and errors.
4. Use of unclear abbreviations or jargon: Using abbreviations that aren’t widely understood or using medical jargon without explanation can lead to confusion and mistakes. “T2DM” is not easily recognisable as a medical condition by someone without medical knowledge.
5. Late documentation: Records should be updated as soon as possible after a patient encounter. Late documentation can result in forgotten details or inaccuracies. Contemporaneous record keeping means that records that are made after 24 hours are usually not legally reliable.
6. Lack of confidentiality: Patient records must be kept confidential and secure. Poor practices in this area can lead to breaches of patient privacy. Records can  sometimes be left open to be seen by someone who is not authorised for access. This can happen both with paper and electronic records.
7. Failure to document consent and best interest decisions: it is important to document that informed consent was obtained from the patient for procedures or treatments. Failure to do so can lead to legal issues. Documentation of consent to treatment in the UK is regulated mainly by the Mental Capacity Act 2005 and some aspects of common law.  Six legal tests are required for a patient to have capacity for each treatment decision. Consent is achieved only after passing all six and then freely communicating agreement [agreement on its own is not consent]. Best interests decisions require demonstration of several statutory duties, in their documentation. Full compliance means heavy time burdens.
8. Not documenting changes in condition or treatment: Any changes in a patient’s condition or treatment plan should be promptly documented. Failure to do so can compromise patient care and lead to misunderstandings among the healthcare team.
9. Copy-pasting in electronic health records: This practice can lead to outdated or inaccurate information being perpetuated in the patient’s record. Copy-pasting is often used as a shortcut, when some health workers attempt to pad their documentation in a belief that nothing has changed with the patient – or that no one will discover their poor practice.
10. Failure to document patient education: It is important to document any education or advice given to the patient, including their understanding and agreement. This can be crucial in cases where adherence to a treatment plan is important.
11. Not including patient’s own words: Especially when documenting symptoms or concerns, it is important to include the patient’s own words. This can provide valuable context and avoid potential misunderstandings. The difficulty here is that most people cannot write faster than 30 words per minute. A majority of people cannot type faster than around 40 words per minute. Most studies find that human speech in English is between 150 and 200 words per minute. Accurately capturing verbatim is difficult for most health services workers.

Time pressures probably underpin most of the above issues. High quality care must be reflected in the quality of documentation. Speech recognition systems exist but are usually come with additional costs. Microsoft OneDrive MS Word comes with speech recognition built in at no additional cost. The challenge would be shifting mindsets of large numbers of staff to a different way of generating documentation, by speaking to ‘a computer’.

Fostering good documentation

Creating an environment that supports good documentation practices in health services involves a combination of training, resources, and organisational culture. Here are some strategies that organisations can use:

1. Training and education: Provide regular training and education on the importance of good documentation and the specific practices that should be followed. This should be part of orientation for new staff and ongoing professional development for all staff.
2. User-friendly systems: Implement user-friendly electronic health record (EHR) systems. These systems should be easy to use and should support the documentation process rather than hinder it. They should also be reliable and secure.
3. Time management: Recognise that documentation takes time and ensure that this is factored into workload and scheduling decisions. Documentation is the work. It must never be separated from ‘clinical activity’ or given lesser importance. Overworked staff are more likely to take shortcuts or make errors in their documentation.
4. Support staff: Provide support staff to assist with documentation where possible. This can include medical scribes or administrative staff who can handle certain aspects of documentation, freeing up healthcare providers to focus on patient care.
5. Clear policies and procedures: Develop clear policies and procedures around documentation. These should be easily accessible to all staff and should be regularly reviewed and updated.
6. Audit and feedback: Regularly audit documentation practices and provide feedback to staff. This can help to identify any issues and provide opportunities for improvement.
7. Culture of quality and safety: Foster a culture that values quality and safety, including the importance of accurate and complete documentation. This should be supported by leadership and embedded in all aspects of the organisation’s operations.
8. Encourage interprofessional communication: Good documentation practices can be fostered by encouraging open communication among different healthcare professionals. This can help to ensure that everyone understands their roles and responsibilities when it comes to documentation.
9. Data protection and security training: Ensure all staff understand the importance of data protection and security, and are trained in the necessary procedures to maintain the confidentiality and integrity of patient records.
10. Incentives and recognition: Recognise and reward good documentation practices. This could be through formal recognition programs or through performance evaluations and promotions.

By implementing these strategies, healthcare organisations can support their staff in maintaining good documentation practices, which in turn can improve patient care, legal compliance, and overall quality.

Take away summary

1. Standards for clinical records: The General Medical Council (GMC) in the UK provides guidelines for doctors on creating and managing clinical records. Key standards include accuracy, timeliness, clarity, confidentiality, retention, access, and data protection. Comprehensiveness was a requirement but may no longer be as per recent changes.
2. Purpose of health service documentation: Good documentation serves several purposes including continuity of care, communication among healthcare providers, legal and professional requirements, quality assurance and improvement, research and public health, billing and reimbursement, and patient safety.
3. Burdens of documentation: Documentation in health services can be time-consuming, complex, require training, present technology challenges, necessitate privacy and security measures, contribute to healthcare provider burnout, and be costly.
4. Poor documentation practices: Common poor practices include incomplete or inaccurate documentation, illegible handwriting, unclear abbreviations or jargon, late documentation, lack of confidentiality, failure to document consent or changes in condition or treatment, copy-pasting in electronic health records, failure to document patient education, and not including the patient’s own words.
5. False documentation: While rare and considered highly unethical and illegal, instances of false documentation can occur due to reasons like covering up mistakes, fraud, performance pressure, and lack of time.
6. Good documentation practices: Factors that contribute to good documentation include accuracy, timeliness, clarity, relevance, confidentiality, consistency, legibility, comprehensiveness, use of standardised terminology, and patient involvement.
7. Creating a setting for good documentation: Organisations can support good documentation by providing training and education, implementing user-friendly systems, managing time effectively, providing support staff, developing clear policies and procedures, conducting regular audits and feedback, fostering a culture of quality and safety, encouraging interprofessional communication, and offering data protection and security training.