Physician documentation can vary in terms of its clarity, completeness, and its usefulness as a means of communication. The quality of the documentation has a very real impact on patient care, and on system performance. The ramifications of poor documentation not only impacts the immediate care of the patient but can have lasting effects well beyond the hospitalization. Clear and complete physician documentation is a cornerstone to improving the lives of our patients, the lives of our treatment teams, as well as ensuring a financially healthy hospital.
The following are examples of documentation that progresses from unclear-to-clear with potential impacts: