INTERPROFESSIONAL GUIDE to DOCUMENTATION in electonic health records

Harnessing the electronic health record to advance integrated care.

“…Three notable factors impeded the ability to use EHR data to examine the interventions and communication patterns involved in today’s integrated care settings: (a) varied titles for clinicians within notes, (b) inconsistencies in the location of notes describing behavioral health and social care components of integrated care, and (c) the notes’ oversimplification of behavioral health or social care team members’ contributions to patient care. Despite these difficulties, analyses identified communication patterns that corroborate recent work describing how EHR documentation serves as a communication tool among members of interprofessional integrated health care teams (Adamson et al, 2020; Rashotte et al, 2016). Earlier work has reported the benefits of EHR for care coordination between clinicians, facilitating patients’ access to their own records and fostering communication within a collaborative environment (Silow-Carroll et al, 2012).…”

“…Allowing clinical encounters to be created by providers regardless of billing permissions could increase the data abstraction process and general usability of EHR data. Creating a common and consistent place to document the behavioral health and social care components of integrated care could assist with systematic data extraction and collaboration (Adamson et al, 2020). In this study, job title had profound implications for identifying notes.…”

“…Because the EHR remains a key source of data across health systems, identifying ways to document team-based care and the contributions of individual team members in the EHR is increasingly critical. This will require training in clear and consistent documentation protocols, which will also facilitate collaboration among integrated care clinicians (Adamson et al, 2020) and learners. Although each health system has a unique EHR platform, health education programs could establish didactic and clinical training to share expectations for EHR documentation and team-based care.…”

A Review of Documentation: A Cross-Disciplinary Perspective

“…In contrast, poor documentation leads to either a paucity or an excess of information that hampers successful project implementation, causes documents to be lost during or after the life of the project, and diminishes the competitiveness of the project team to win a subsequent tender [8]. In health care systems, documentation is also critical in providing good care, supporting and structuring inter-professional and doctor-patient relations, and contributing to clinical efficiency [9].…”

“…In health care systems, "shadow client files" have emerged, consisting of "entries that are not included in the official chart of the facility and are maintained by the health care professional for some time for private use" [9]. Such private documentation presents a risk to practise (e.g., patient's privacy) and jeopardises client care [9]. The problematic sides of digitalisation have already emerged.…”