Why Give a Documentation Workshop?

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I just had a tumor removed, but nonetheless I am set to give a documentation workshop at the Connecticut Women’s Consortium this June. In my mind, these things make sense. One is the removal of a life-threatening mass, and the other is the removal of a life-threatening mass. Because I need to write about the clinical workshop, I’ll stick to that today, but let me add the tumor that was removed was, and possibly still is, set to kill me, just not today. In a similar sense, the medical record persists. Everything you write down today will matter in the future. Our goal is to learn what, how, and why.

Our medico-legal records cover a host of issues. They deal with our insurers and drug companies, allow us to communicate amongst ourselves, let patients have information they want/need, and defend ourselves—or don’t—when we get hauled into court. They handle buckets of material. And if we don’t have a strong and persistent sense of what we’re doing with them, there is massive room for problems.  

However, they are not all that difficult once you have a general handle on the material. Here are six areas that I will cover:

  • Understand who reads the medical record. This will key you into what needs to be there. If this could be read by peer specialists, family, attorneys, judges, nurses, doctors, social workers, and physical, occupational, and speech therapists…you must ensure the material is presented as they will appreciate it.

  • Understand and use both The Golden Thread and the Joint Commission’s Tracer Methodology. These will provide you with start-to-finish clinical documentation. What was the issue, and how was it handled?

  • Stick to the facts. What happened? What did you see, hear, feel, taste, etc.?

  • Every time you see a patient, make sure you cover deal-breaker issues such as suicide and thoughts of harming other people. These should be hardwired into your documentation.

  • Understand how to consistently put numbers on difficult things like depression, trauma, psychosis, and anxiety.

  • Write and sign your notes daily.

The medicolegal record needs to focus on what you can observe. Yet this easily becomes lost as people get swept up with judgmental words like malinger, falsify, co-dependent, and enable, when the reader needs a clear description of what just happened. “She was upset with her boyfriend and took a bottle of pills as he watched.”

What I hope to do on our day together is wrap all this into a usable model. Clinical documentation is not difficult, but we all need someone to walk us through it, at least once. You can learn how to do it in a day, and I hope you are able to clear out the space in your calendar and join me this Friday, June 11 through the Connecticut Women’s Consortium. 

Charles Atkins, MD is a psychiatrist, author, and professional speaker. His website is www.charlesatkins.com. Stay updated on future training opportunities here: https://womensconsortium.configio.com/

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