Many professionals who seek careers in the healthcare arena do so because they innately want to help others. Very few, if any, think to themselves, “I’m going to write the best and longest care plan and notes!” And yet, that is exactly what most healthcare professionals spend the majority of their time doing. Documentation helps to establish stable routines and fosters regular communication among staff in the same and different disciplines. One of the first and most important principles taught is this: “If you didn’t document it, you didn’t do it.” This rule is meant to protect both patients and providers, but in very different ways.

In patient care organizations, proper and accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing. As such, Documentation Improvement Programs (DIP) are important to any facility that recognizes the necessity of complete and accurate patient documentation.

For patients, documentation ensures the delivery of safe, consistent, quality healthcare. Documentation is often the sole point of communication between staff that are changing shifts. This means that if no verbal conversation has taken place, the documented notes must be read by the oncoming staff to understand where in the care cycle the patient stands. 

At the core of the problem is that healthcare providers are extremely busy and because of that, they’re not connecting the dots on documentation. The best way to deal with their demanding schedules is to engage them in a positive way, train them, and give them time to see the relevance in improving their documenting. Take them through training to help them understand what they’re doing today and where there are areas for opportunity to do a better job documenting.

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