Including these three guiding principles into your medical records will guarantee they are concise, consistent, and serve as adequate protection against any possible lawsuit.ĭepending on your preference as a physician, there are different format templates you can use to create your notes. This means you should record whether the patient understands any potential side effects of medication, the symptoms they may experience, what constitutes a medical emergency and whether they know who to contact in the case of said emergency. Lastly, your documentation needs to refer to the patient’s capacity to understand their own role in managing their care. If it is determined you made a false decision, as long as your mistake was based on logical clinical reasoning, it is unlikely to be determined as negligent. This may seem obvious, but as someone with both objective and subjective perceptions, all of your decisions need to be backed up by clinical reasoning. Secondly, you must include references to your clinical judgment. For example, if a physician decides to medicate a patient, not only do they need to outline the associated risks, such as their aversive side effects, but they should describe the benefits of the medication and the risks of not taking the medication. To consolidate your understanding of what constitutes a good clinical note, we have collated some of the basic principles that should always be incorporated.įirstly, it is important to provide an explanation of both the risks and the benefits associated with a treatment decision. Ensuring that your patient is receiving the best treatment should be the absolute primary objective of delivering healthcare services, and this is heavily assisted by clinical documentation. Writing poor medical records not only has negative implications in regards to legality and insurance, but they are a breach of proper duty of care. Whether you are a general practitioner, nurse, psychologist, or therapist, improving your clinical documentation is always in your best interest, and that’s where we can help! To guarantee that your notes will effectively benefit you and your patients, they need to be consistent, timely, and accurate. Different practitioners have their own preferences for how they create their notes, and can decide whether to use digital or analog documentation methods. Writing good clinical notes has various advantages for both you and your patient, regardless of what field of healthcare you work in. Clinical notes are also used as evidence in legal situations or by insurance companies, so maintaining good documentation can protect your practice, and ensure you receive reimbursement for your services. These notes are often used as references in instances of inter-provider communication and can facilitate effective continuity of care. As a physician, you are required to create records that relate to the medical treatment of any patient that you see. Clinical documentation is an integral aspect of working as a healthcare professional.
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