Healthcare documentation has gone through numerous changes over the years to adapt to the industry’s dynamic and ever-changing nature, as exemplified with the move from the pen-and-paper charting used during the earlier years of organized and standardized healthcare delivery to today’s online software use and telehealth capabilities.

As the methods for documentation increased, so did the issues and challenges associated with them, further highlighting the need for quality. Good patient outcomes rely on accurate records, so every team member should know what goes into quality documentation.

Quality Documentation Best Practices

Every clinician documents differently, which makes coding for claims more difficult. Regardless of who wrote it, documentation must be accurate, have the right context, be authentic, easy to understand, trustworthy, timely and relevant.

Use these best practices to ensure quality in documentation:

1. Who, What, Where, How and Why – Familiarization with the patient’s case can help prepare the clinician for how to tackle the visit, starting with the name of the patient, the diagnoses, where and how the visit will be handled and what tools are going to be used. This helps ensure that the information gathering process will be systemic and organized, with less chances of error.
2. Be Like Boy/Girl Scouts – After becoming familiar with a patient’s case, it is best to be prepared for any situation that may arise. Though it is not possible to be prepared for every potential scenario, the clinician should at least be prepared enough to tackle possible scenarios relevant to the patient’s condition (e.g., weighing scale if the patient has congestive heart failure or wound care supplies if the patient has a wound). It also helps to ensure that the “tools” used are in optimal condition.
3. Review and Arrange – Always check and recheck the information gathered to scan for inconsistencies and problems. Arrange the documentation in a neat and legible manner, as if plotting a story, making it easier for readers to understand.
4. Verify and Confirm – The accuracy and validity of any information gathered depends on several factors and may not always be top notch, so it is important to always compare with other legitimate sources of information (e.g., face-to-face document, referral documents, hospital records) relevant to the patient’s case. This way, you can ensure that what was documented is as close as possible to the patient’s case.
5. Communication Is Key – Healthcare is a collaborative effort. This is also true for healthcare documentation. Quality documentation is only possible if all of those involved properly fulfill their roles. Proper coordination with the team is important and ensures errors are minimal. This also guarantees that any missing information, discrepancies or inconsistencies are identified and resolved as early as possible.
6. HIPAA Compliance – Multiple safeguards should be implemented to protect the patient’s personal and sensitive health information.
7. Continue to Learn, Study and Train – This industry is dynamic. In order to adapt to new health trends and updates, individuals must strive to improve themselves. By doing this, clinicians will be more competent and effective with healthcare documentation.
8. Right Tools for the Right Job – Having the right tools is vital to finishing a task or a project properly and can ensure high-quality documentation. Tools may refer to hardware, software and skills that an individual may use.

High-quality documentation not only ensures that patients receive the best care possible but is also important to securing revenue and proper reimbursement. This makes quality control in documentation critical to an organization’s success.

Axxess Home Health, a cloud-based home health software, allows for documentation at the point of care, with a built-in quality assurance center for accurate and timely claims.