Medical Documentation in Health Processes: What It Is and Why It Matters

Healthcare providers document patient care in various ways. Some use paper records while others have switched to digital systems. Regardless of the method used, providers must document the details of their interactions with patients in a way that is useful and accessible. This article focuses on medical documentation, identifying what it is, why it matters, and best practices for creating documentation that is useful for future reference.

Working as a healthcare provider requires frequent contact with patients. Keeping up with notes on each patient can be a challenge. If not done properly, these notes can be difficult to find later or may not provide enough detail about the interaction between the provider and the patient. When done correctly, medical documentation serves several purposes:

Readers of this article will learn what medical documentation is, why it matters, the different types of documents used to record patient information across various healthcare settings, examples of specific documents used by different healthcare professionals and practitioners, tips for creating effective and accessible documentation regardless of whether a paper or digital system is used, and common mistakes to avoid when documenting patient interactions.

What is medical documentation?

Medical documentation is the written record, or notes, of a healthcare provider's assessment, diagnosis, and care plan for a patient. Documentation is usually recorded on paper or in digital format, such as an electronic health record (EHR) or a medical transcription service. In the medical field, documentation is an essential part of the healthcare delivery process, as it records the patient's history, the conversations between patient and provider, and the patient's current health status. Accurate and complete documentation is important for many reasons. It provides a trail of the healthcare services provided to each patient (which is beneficial for billing and record reviews), helps ensure that each patient receives the best possible care (for example, by providing consistency among providers and across different settings), and allows providers to communicate accurately and efficiently with other healthcare professionals. The goal of documentation is to accurately reflect what happened during the encounter between the provider and the patient. The information contained in the documentation is essential for the delivery of care, including the diagnosis, the treatment plan, and the instructions given to the patient.

Why is healthcare documentation important?

Healthcare documentation is important because it provides a record of the patient's care, treatment, and progress. It also records discussions between the provider and the patient, and can be used to assist in future care or decision-making. For example, documentation can help inform treatment decisions when a provider is out of town or unavailable to decide on a course of action. When documentation is complete and reflects the patient's current status, it is easier to make decisions about future care. Documentation is also used for billing purposes.

Types of healthcare documentation

There are three main types of healthcare documentation: narrative, descriptive, and instructive. Narrative documentation is a description of the encounter between the provider and the patient. It is written in paragraph form and is not intended to be used as a reference tool later on. This type of documentation is useful for recording the patient's account of their illness and history, as well as for communicating with them. Descriptive documentation is a summary of the encounter between the provider and the patient, but it also includes the patient's account of their illness and history. Descriptive documentation also includes a list of medical findings, or the assessment. This type of documentation is intended to be used as a reference tool. For example, a provider may use descriptive documentation to note the findings of the patient's examination, laboratory test results, and medications. Instructive documentation is a written or typed summary of the provider's instructions to the patient. It is written in a way that is easy to understand and follow, and is often written in "plain language" to ensure patients understand the instructions. This type of documentation is only applicable to certain healthcare settings, such as outpatient clinics.

Electronic Medical Records (EMR) and Electronic Health Records (EHR)

An electronic medical record (EMR) is a computerized database that contains each patient's medical history, as well as the details of each encounter between a provider and a patient. An EMR can include a variety of documentation types, including narrative, descriptive, and instructive. An EMR can facilitate communication among providers, patients, and other stakeholders, such as researchers, by making information easier to obtain. An electronic health record (EHR) is the same as an EMR, except that the data is typically stored on a central computer server, rather than on a computer at each provider's location.

Laboratory and diagnostic test records

Laboratory and diagnostic test results are frequently recorded in a medical record. These results are often recorded in narrative format as a brief description of the findings (for example, "The patient's blood pressure is 130/80") or in table format. A table format may include the patient's name, the name of the test, and the result.

Medical imaging records

Medical imaging records document the findings of a patient's imaging studies, such as X-rays, MRIs, CT scans, and ultrasounds. Results are usually recorded in narrative format, but they can also be recorded in table format.

Medication prescription records

Medication prescription records document the medications prescribed to patients. This documentation can be recorded in narrative or table format.

Summary

Now that the article has been explored, it is time to summarize the key points to ensure the reader is equipped with a solid understanding of the content. This section is intended as a quick reference guide to help you navigate the article and conveniently reference the key ideas.

Medical documentation is the written record of a healthcare provider's assessment and care plan for a patient. Documentation is important for many reasons, including providing a history of the patient's care, helping ensure that the best possible care is provided, and allowing providers to communicate accurately with other healthcare professionals. There are three main types of healthcare documentation: narrative, descriptive, and instructive. An EMR is a computerized database that contains each patient's health history, as well as the details of each encounter between a provider and a patient. An EHR is the same as an EMR, except that the data is typically stored on a central computer server.