Documentation Design: Palliative Care Notes in the EHR Era

by April Krutka (@April918) and Christian Sinclair (@ctsinclair)DOCUMENTATION...who knew this one word could provoke so many emotions among health care clinicians? Say this word, and you will hear stories of triumph and defeat. From universal required elements in the admission history and physical, progress notes and discharge summaries to the specialty specific language of advance care planning and pain assessments, there is a constant pressure to get all the pieces to fit correctly. Moving from analog to digital offered much hope, but also new problems. Before we even start typing or dictating a new note, most of the success or failure lies in how we design our notes from the start.Standardized documentation promises clinicians consistency, data tracking, opportunities for quality improvement, and inclusion of essential elements of a specialty. If a template is built well, it should save time and impact the clinician experience and patient care in a meaningful way. Designing templates can be like walking a tight rope. Fall on either side, and it can lead to burnout and frustration by those using the templates.There are many stakeholders who have a vested interest in the components of a clinical note. It is used by many different entities for different reasons: the billing department wants to submit the correct bill, the clinician/team needs to communicate clinical plans, the patient wants to be assessed accurately and without stigma, payors want to make sure they are paying...
Source: Pallimed: A Hospice and Palliative Medicine Blog - Category: Palliative Care Tags: documentation krutka sinclair Source Type: blogs