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INTRODUCTION

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I write entirely to find out what I'm thinking, what I'm looking at, what I see and what it means.

— Joan Didion

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*Mr. Ketterman's Case

Mr. Ketterman has so many issues that we are addressing. I want to be able to keep track of them all and I would like to be able to use what I learn from his care to help me with future patients. How can I manage this in my busy day? (See Appendix for Mr. Ketterman's health history.)

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In Section III, we discussed identifying, assessing, and applying, as appropriate, evidence from the research literature to decisions about patient care. Yet, it is apparent that the research literature does not hold all the answers to all the questions we have about patient care. In Chapter 19, Drs. Bise and Delitto discuss an approach that uses the data generated in everyday care as a source of evidence. This approach, as with many evidence based activities, relies on documentation to be successful.

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The goals of this chapter are to examine the multiple purposes of documentation and how these purposes may be met in producing accurate and useful documentation about a patient's condition. Thus, improved documentation can become a source of evidence that aids in decision making.

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THE HEALTH CARE RECORD

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The patient/client record serves multiple purposes. According to the American Health Information Management Association (AHIMA), documentation has many purposes. For most clinicians, most of the time, the primary purpose of documentation is to provide a basis for clinical reasoning in planning care and assessing its success for the individual patient. Ideally, the patient/client record also serves as a communication tool for providers involved in the care and supports patient/client care delivery. Appropriate and meaningful documentation is important to support optimal decision making, to minimize risk, to promote continuity of care, and to determine the best plan of care for the patient/client.

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Documentation is also a mandatory practice, subject to applicable jurisdictional and regulatory requirements. There are specific legal requirements about when and how to document patient care and charting errors. There are additional requirements for signature and other means to demonstrate the authenticity of the record. Payment for services is justified through documentation in the patient/client record. Different payment sources have specific mandates for documentation to justify both approval for services and to determine which, if any, services are eligible for payment.

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All of these purposes matter in patient care, but the last one, a means for data collection and retrieval, may be the most important in terms of evidence based practice. When the clinical record contains standardized information, then these data can be retrieved and analyzed, both within and across practices. Secondary purposes are education, regulation (compliance and accreditation), research, policy making (allocating resources and business planning), and industry needs (including research and ...

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