House and attending staff are responsible for ensuring the full documentation of all patient information at BWH. In addition to other caregivers, physicians are encouraged to use the guideline of “anything that advances the care of patients” when deciding what clinical information to document.
“Documentation has long been critical to patient care, but as new ACGME limits on residents’ hours go into effect and more clinicians are likely to participate in the care of any given patient, proper documentation becomes even more crucial,” said Janet Barnes, director, Risk Management at BWH. “Our documentation should simply reflect the high quality of care provided at BWH.”
Some documentation guidelines to follow are:
- include objective, factual data
- include relevant patient information only
- document information related to the treatement plan
- document information related to treatment rationale
- include the patient’s response
- note patient complaints/compliance issues
- make sure documentation is legible, including signature and title
All clinicians are reminded that if key information is not documented, there is not record of an event, procedure or other action as having taken place. The quality of care provided to patients is reflected in appropriate, complete documentation in the medical record.
For further clarification on what to and not to document or other more detailed information on documentation, contact Risk Management at ext. 2-6442.