Many aspects of healthcare require proper documentation in order to run smoothly. This includes everything from documenting patient information and treatment plans to managing financial records. As such, failure to document information accurately or share the information correctly can have significant consequences for the patient, provider, or organization. Virtually all forms of healthcare, including behavioral health and addiction treatment involve the management of a large amount of documents and records, and therefore this can also be a significant challenge for healthcare providers.
Educate Your Team About Proper Procedure and Best Practices
One of the best steps you can take to maintain or improve the quality of the documentation at your facility is by ensuring your team is properly trained and informed of procedures related to documentation and record management. This training should take place during onboarding and then refreshed on a regular basis. The team should also be updated when any changes to procedure are implemented, and they should have a clear touchpoint for communication if any questions arise. For example, if a professional conducting a mental health evaluation cannot find pertinent patient records, they should know exactly who to contact and what channels to contact them through.
Minimize Shorthand and Jargon
While some shorthand and jargon can be used effectively within an organization, overuse of them can complicate and obfuscate medical documents. Shorthand, acronyms, and jargon should particularly be avoided if they are not consistently used within your facility or if the information may be shared outside of the facility (e.g. with other specialists collaborating on patient care). When in doubt, it is best to clearly state and write out information so that the meaning cannot be mistaken. For example, it would be better to write, “Patient is diagnosed with addiction to substances including alcohol and narcotics” rather than “Addict. alc. & narc,” in the notes of a patient’s medical records.
Refine Your Intake Procedure
One of the times that a facility collects the most information from patients is during intake. This is not only important for establishing patient records, but also to create a baseline from which you can track progress and measure outcomes moving forward. As such, it is vital that this information is complete and correct. This includes everything from medical history to contact information to billing information. In order to ensure this information is collected correctly, the intake process should be consistent and efficient. At specialized facilities such as addiction treatment centers, the intake process may also involve unique elements such as urine analysis, and therefore should ensure that they review and implement standards and effective protocols related to those aspects of intake as well.
Improve How You Communicate With Patients
The best way to ensure the information you get from the patient is correct and thorough is by communicating with them effectively in the first place. As such, healthcare professionals should be great communicators, or at least develop key communication skills and emotional intelligence that can encourage patients to share information with them and allow them to glean the necessary insight. Some ways that you can improve your communications with patients include:
- Using active listening;
- Asking open-ended questions;
- Keeping an eye on body language;
- Getting a read on how forthcoming they are;
- Recognizing barriers to communication;
- Asking for clarification as needed;
- Reading information back to them for review;
- Telling them where and how to correct their information if needed;
- Avoiding jargon;
- Building rapport;
- Projecting positivity and a welcoming attitude;
- Identifying and pursuing key concerns.
It may also benefit you to review the patient’s information beforehand in order to take notes about what you want to say to them in order to make sure nothing falls through the cracks.
Review Documentation for Opportunities for Improvement
You may find that there are opportunities for improvement in documents or documentation procedures over time. These may result from initial oversights or the gradual obsolescence of procedures and standards. Take note of any consistent issues or concerns, and ask for feedback regarding such issues. Then, on a regular basis, you should review document templates and documentation procedures to see any opportunities to address these issues or otherwise improve or streamline processes. For example, you may find that a simple checklist is insufficient for health history and may choose to add an open space for the patient to discuss any other unlisted concerns.
Use Helpful Tools and Software
Human error and inefficiency is a common cause of issues with documentation. As such, various tools and software can improve the process by automating tasks and making document management more efficient, especially with the rising prevalence of AI in behavioral healthcare. These tools may also notify you about issues such as an empty field or a missing signature. For example, EHR software can provide a structured format for data entry, centralize all documents for ease of access, and improve legibility through digitization. In short, the implementation of digital tools can have substantial positive outcomes on the quality of your records and the ability of providers to access and interpret them properly.