Documentation Done Right: 7 Questions to Ask that Can Help Improve Quality of Care

Clear, accurate and timely documentation is critical to providing quality patient care. Help sharpen your documentation skills with these key questions.

On January 4, 2020, EMTs responded to an emergency call to the home of Robin Phillips. When they found Phillips, a 28-year-old woman with severe autism, she had been dead for several hours and was severely bloated from constipation. The local coroner ruled Philips’ death as, “an overdose of the anti-psychotic medication chlorpromazine, as well as caretaker malfeasance” according to Courier & Press.

Phillips had been under the care of three home health aides who are now charged with negligence resulting in catastrophic injury, and their employer is facing a civil law suit.

Courier & Press reports that the home health agency’s director told police Phillips’ medical records were missing key documentation and contained incomplete paperwork regarding her medication. Another employee told the paper, "There are holes in the paperwork all the time. If I come in on third shift and people aren't doing the paperwork — and upper management is not constantly checking — how am I going to know if a client hasn't had a bowel movement in three days?"

While it was not the sole cause of Phillips’ death, the case does highlight the pitfalls of poor documentation. Inaccurate information, incorrect timestamps, and incomplete paperwork can all lead to mistakes in treatment, evaluations, testing and follow through of the care plan.

Make high-quality documentation the standard

Providing the best patient care often relies on providing high-quality documentation. Accurate, thorough and timely documentation provides a means of clear communication with other team members and a record of actions taken within the care plan. The Journal of the American Health Information Management Association identifies these 7 characteristics for high-quality documentation:

• Clear
• Consistent
• Complete
• Reliable
• Legible
• Precise
• Timely

Regularly taking stock of how well you are meeting these standards can help you to improve your documentation skills. Ask yourself these questions when reviewing your patient records:

1. Can I or other team members read my own notes or signature?

If your notes are illegible or hard to read, other members of the care team will either have to take valuable time deciphering them, or flat-out guess at what they say. Either way could come at the cost of patient care.

2. Do my notes allow me to visualize a specific patient at a given time – or do they all sound the same?

Copy and paste may be a life-saver for some careers, but not for caregivers and healthcare providers. Defaulting to the same descriptions for each visit or even every patient can lead to leaving out important information and updates.

3. Are my notes dated and timed accurately?

We get it – sometimes it can be hard to remember what day it is, especially when you’re following the same routine every day. But keeping your timestamps accurate is essential to providing quality care, especially when it comes to medications and patient vitals.

4. Are forms filled out completely?

Skipping a few questions that might not apply may seem innocent enough, but the more complete a form is, the more accurate it tends to be.

5. Do my notes clearly indicate the actions I took to resolve problems identified in the plan of care?

Life doesn’t always go according to plan, and the same can be said when it comes to caregiving. Keeping a record of unexpected issues, new problems and patient incidents is crucial to maintaining high-quality documentation.

6. Do my notes show that I notified other team members if additional action was required?

Let other care team members know what to do or how they should address a similar issue with the patient – and then document when and how you communicated this information.

7. Could I defend my care of a patient based on my documentation?

If your records do not meet the criteria of high-quality documentation, this could be an uncomfortable question to ask yourself. No one wants to be the defendant in a criminal or civil case, but if the worst were to occur, would you feel confident based on your documentation?

Patient care is, without a doubt, the highest priority for caregivers. So much so, that other daily tasks may take a backseat or become so routine that they feel burdensome. But documentation should always be considered a crucial step to providing the highest quality care.