A qualitative investigation into clinical documentation: why do clinicians document the way they do?

Abstract

<jats:sec><jats:title>Background:</jats:title><jats:p> Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. </jats:p></jats:sec><jats:sec><jats:title>Objective:</jats:title><jats:p> To gain an in-depth understanding of clinician documentation practices. </jats:p></jats:sec><jats:sec><jats:title>Method:</jats:title><jats:p> A qualitative design using semi-structured interviews with clinicians (allied health professionals, doctors (physicians) and nurses) working in a tertiary-level hospital in South-East Queensland, Australia. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> Several themes emerged from the data: environmental factors, including departmental policy and systemic issues, and personal factors, including verification, clinical reasoning and experience influencing documentation practices. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Our study identified that the documentation practices of clinicians are complex, being driven by both environmental and systemic factors and personal factors. This in turn leads to duplication and some redundancy. The documentation burden of duplication could be reduced by changes in policy, supported by multidisciplinary documentation procedures and electronic systems aligned with clinician workflows, while retaining some flexible documentation practices. The documentation practices of individuals, when considered from the perspective of enhancing quality care, are considered legitimate and therefore will continue to form part of the health (medical) record regardless of the format. </jats:p></jats:sec>

Self‐reported documentation of goals and outcomes of nutrition care – A cross‐sectional survey study of Scandinavian dietitians

“…Findings might, therefore, reflect overreporting. Other factors, such as time, technical issues, knowledge, and motivation, have been associated with documentation practice but these have not been addressed in this study [1, 20, 27]. Further research is needed to explore whether these factors are associated with the documentation of goals and outcomes.…”

“…Although the widespread use of electronic health record (EHR) systems in Scandinavia may facilitate this process [22–24], a number of studies have revealed inadequate documentation of patients' goals and outcomes [2–4, 13, 25, 26], not least in nutrition care [14, 15]. Factors such as work experience and clinical judgement may influence documentation practices [1, 20, 27]. For example, higher education among nurses is associated with greater expertise and improved quality of care [28].…”

“…Documentation in patients' healthcare records is an essential component of health care [1]. It supports verbal communication, the clinical decision process, and transparency of care, and improves the transfer of clinical information [1][2][3][4][5].…”

“…Documentation in patients' healthcare records is an essential component of health care [1]. It supports verbal communication, the clinical decision process, and transparency of care, and improves the transfer of clinical information [1][2][3][4][5]. The documentation of patients' goals and outcomes is particularly important in the provision of person-centered care, evaluation of the quality of care, patient safety, and continuity of care [6][7][8].…”

Recognising complexity: Foregrounding vulnerable and diverse populations for inclusive health information management research

“…This finding indicates that the intersection of several allied health disciplines in providing care to patients with multiple conditions (e.g., increased social, dietary, physical, and communication support needs) is potentially splintering the health information. The complexity of clinicians' documentation practices is influenced by environmental, systemic, and personal factors (Rowlands et al, 2020). This suggests that health systems and documentation management should recognise, value, and promote complexity in the patient and in the clinician.…”