It’s Not Your Staff, It’s Their Charting: 3 Elements That Healthcare Professionals Should Document

Updated: Jan 8

So a healthcare professional isn’t working up to the standards of your organization—don’t be so quick to categorize them as unqualified. Most of the time, problems like this can be remedied by direct communication of documentation needs. For healthcare workers, the importance of accurate and timely charting must be emphasized.

Why is Charting Important in Healthcare?

A medical or healthcare chart is a comprehensive record containing the patient’s medical history, vital signs, clinical data, diagnoses, medications, treatment plans, and other pertinent information that are not only critical in the delivery of care but also critical in the quality rating of healthcare organizations which is often tied to revenue.

While healthcare innovation continues to streamline documentation practices, the need for charting critical elements of a patient's care remains relevant. The importance of accurate charting lies in the healthcare outcomes and patient outcomes that are dependent on the information contained in those charts.

3 Elements to Always Document in Healthcare

1. The H & P Exam

History and Physical or the “H & P '' exam of the patient contains critical information as to why the patient sought healthcare services or received medical attention. It is also helpful in developing a diagnosis based on the patient’s medical history. There are several elements of the H & P that tie into quality rating such as ensuring the documentation of a history of diabetes so that a treatment plan of quarterly A1C’s are obtained to ensure measures such as HEDIS are met which again relates to quality delivery of care. In addition, ICD-10 diagnosis codes are generated from this information which is needed for billing.

2. Initial Lab Findings and Test Plans

The result of the lab tests undergone by the patient is important in determining the kind of treatment that should be given to the patient. Also, it’s critical to track the progression of implemented treatment regimens to assess the effectiveness of interventions. This is where the measurement of quality comes in because it is clearly documented where the patient started, the effectiveness of the treatment plan, and ultimately the outcome.

3. Progress Notes

Progress notes are full of value! They contain key critical information on the overall progression of a patient that feeds off of the initial H & P, which can serve as a gold mine for the extraction of data that contributes to quality. Key information that should be included within the progress note includes but is not limited to: daily/frequent weights for congestive heart failure patients, labs such as cholesterol levels, head-to-toe assessment findings, education provided to patients, etc. This is the information that can tell the true story on the outcomes of the patient and also show regulatory agencies such as the Center for Medicaid and Medicare Services ( CMS) the delivery of quality care your organization provides to consumers.

Ensuring these 3 core elements are precisely and consistently documented within your healthcare organization is a sure way to ensure positive healthcare outcomes for the consumers you serve on a daily basis and improvement of your organizations quality delivery of healthcare rating, which leads to increased revenue that allows for continuous improvement of the healthcare operations.

Impact Nurse Consulting | |

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