Ellenia Van

Professor Sara Thames

ENC1102

10/07/20

From Notes to Patient Charts; How can healthcare workers improve clinical documentation?

Introduction

Everyday healthcare workers are always working with many patients and it becomes hard

to keep up sometimes. With every situation, diagnosis, or plan, it is up to clinical documentation

to tell the next person reading a patients chart. It is important for many healthcare workers like

nurses to keep good clinical documentation because it allows others to see a patient's condition

and plan of treatments. Clinical documentation can be seen like a map, there are many details

and plans but the destination is like the final treatment. Throughout my research, I found many

methods for improving the quality of clinical documentation with the help of textual analysis and

first hand observations at an outpatient family medicine practice. My first day working as a

medical assistant, I was blindsided by the amount of information that needs to be documented

but I also saw the effects of when information was not documented. There would be days where I

had random scratch paper falling out of my pockets or little side notes on my hand so I would not

forget to document it. I also have a sister that is a registered nurse at the Orlando Health

Regional Medical Center and she has explained to me the importance of patient charting, reports,

round notes and many more aspects to documenting. It made me realize that having an organized

system and education on clinical documentation is a major foundation to the medical field in

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general. In my research, I was able to find different ways nurses can improve their clinical

documentation skills which should be a requirement for nurses in general.

Literature Review

In my scholarly research, my main discourse community I focused on were nurses and

medical assistants. Based on the definition of discourse community, “ where communities of

practices are seen as complex collections of individuals who share genres, language, values,

concepts…”(Wardle and Downs 319), the discourse community I chose was based on a

professional setting. ​For my research topic, my main objective was analyzing ways to improve

the quality of clinical documentation. I was able to do this by reviewing three scholarly articles

relating to my topic and each provided by using my UCF online library database. The beginning

process of finding my secondary sources consisted of typing in keywords like “clinical

documentation”, “nursing documentation quality.” After finding 3 sources that related to my

topic, I was able to go back and used my knowledge about critical reading. My uses of critical

reading consisted of annotating, breaking down the information provided, and sifting through

quotes that stood out to me.

From every article I analyzed, it was clear how each nurse or nursing assistant shared the

same language through medical terminology and all had the same goal of making sure patients’

documents were accurate. The name of the practice is not disclosed in my research for ethical

purposes. No matter what hospital or nursing position someone is in, there is no doubt that it

does not include clinical documentation. Another research found that the “​mean rates of 633-689

manual flowsheet data entries per 12-hour shift in the ICU and 631-875 manual flowsheet data

entries per 12-hour shift in acute care, excluding device data” (Collins et al 2018). On top of

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their long hour shifts, nurses have to be able to maintain the ethical standards within clinical

documentation where patients' health records consist of quality care, correct coding, and high

quality reporting of a patient’s condition. There has been much research done on ways to

improve the quality of clinical documentation, but even with that research, clinical

documentation is an endless process where there can be improvement.

Some research has shown the improvement of clinical documentation through training

programs. One which was called Clinical Documentation Quality training that consisted of

measuring the residents ability to document cases with the criteria for high quality

documentation that was clear, timely, and accurate (Ruthann et al 2013). This research was

similar to where Mahlegha Dehghan and her colleagues evaluated the effects of clinical

governance on documentation. Clinical governance is the systematic approach to improving the

quality of the patient care within the healthcare system. Dehghan’s research consisted of two

5-hour workshops for nurses and nursing assistants. Both research articles incorporated the

effects of the clinical documentation programs where in conclusion it helped improve their

documentation overall, but the only difference was that Dehgan used a checklist system that

measured 19 structures of random samples of clinical documents. The 19 structure consisted of

different qualities of a good complete clinical document.

Specifically to my research that was done at a Primary Care Clinic, it is important for

when patients that come in to follow up or are new to the clinic have an accurate patient’s health

summary from previous locations. Their health summary includes but are not limited to

medications, conditions, past medical procedure or diagnosis. In a ​more recent research, Peterson

et al. demonstrated that among 80 patients presenting to a primary care clinic with a previously

undiagnosed condition, the history produced the correct final diagnosis in 76% of the visits. The

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importance of clinical documentation plays a major role in the medical field because nurses,

nursing assistants, or doctors rely on that information to be able assess a patient’s problem or

treatment plan. A patient’s clinical documentation is not only important for the doctors but also

many other healthcare providers like pharmacists, who deal with a patient’s medication. Not

every clinical documentation is spot on perfect, but it is important that it is accurate. In an event

where there has been an error, for example if a patient’s medication were typed in wrong, the

problem should be fixed right away as it may have major effects on the patient’s health.

Methods

I was able to collect my own primary data through an interview with some nurses staff

that I work with and also through observation. ​Before starting my interview process, I took a

Collaborative Institutional Training Initiative program where I learned the ethics and legal aspect

of research involving human participants. I structured my interview questions in a way that it

avoids bias, conflict with participants, and avoids conflict of where my sister works. The CITI

training was a great learning experience of how to produce productive and ethical research. ​My

questions consisted of how the nurse felt about clinical documentation and what improvements

in the field should there be. Before my brief one on one interviews, I had to obtain an informed

consent form. With the answers I got from my sister, I was able to draw comparisons with my

experience working as a medical assistant at an outpatient clinic and drawing connections to a

speech given by Patricia W. Iyer called, “Documentation: Avoiding the Pitfalls,” which

examines the effects on bad clinical documentation. ​ ​Patricia Iyer is an LNCC (Legal Nurse

Consultant Certified). Iyer shares her knowledge to help other legal nurse consultants excel in

the field and highlights the importance of clinical documentation..

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 From the interview, I can draw my own connections because another part of my primary

research is incorporating real life experience at my workplace. I currently work as a medical

assistant at an outpatient clinic. My experiences with clinical documentation is very beginner's

level but it provides a different perspective from me being a medical assistant and my sister

being a nurse. There are definitely comparisons and differences.

Another primary source I plan to incorporate is an EMDs template, which is an

Electronic Medical DataBase System. This is the database template I use at my workplace. It

shows an example of what a patient’s chart would look like. Some examples that are shown in

Figure 4 below are a patient’s history of medication, current problem, past medical history,

family history, and etc. Having a well informed and clear patient chart is important in a medical

workplace. With this primary source, I will be able to explain my personal experience with

clinical documentation. For example, coding plays a major role with the insurance side of a

patient. If a doctor forgets a code, it can lead to a potential big bill for the patient to pay or

confusion within the workplace.

Results

Coding Within Clinical Documentation

Working as a medical assistant at an outpatient clinic has taught me a lot about clinical

documentation. In my appendix, I have included an example of an EMDs patient chart template I

use at my workplace. A major part of clinical documentation is learning about diagnosis codes

and insurance. Clinical documentation is a major role to my job when helping the provider and

doctors. As a medical assistant, it is common for providers to request us to order labs for

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patients. For example, a well known lab location is Quest Diagnosis. Quest Diagnosis has an

electronic order system where providers or medical assistants can place lab orders for patients

online. Coding plays a major role in ordering labs. Based on my experience, when ordering labs,

there can be instances where providers or doctors forget a diagnosis code that can leave a patient

a big bill. For example, if a doctor orders a patient to get blood work done and the specific test is

a comprehensive metabolic panel, a diagnosis code that would cover that test would be mixed

hyperlipidemia which the ICD-10, ​International Classification of Diseases,​ code is E78.2. In

cases where the ICD-10 code is not documented, patient’s are left with a balance to pay. That is

why clinical documentation is important for providers, as they are responsible for documenting

diagnosis codes.

Analyzing Discourse Communities Within Clinical Documentation

A medical workplace most likely consists of a provider, which is most likely a doctor and

medical assistants or nurses that work under them. Throughout my primary research findings, a

common topic that was present was the feeling of intimidation when it comes to clinical

documentation. A problem with clinical documentation is when notes or diagnosis are not clear,

which can lead to the need for clarification. In Patricia Iyer’s speech about the problems with

clinical documentation, she highlights a medical case in North Carolina where nurses felt

reluctant to approach the “​obstetrician because he had a response that was typically negative

when nurses approached him about concerns about a patient so they did not approach the

physician,” and this situation ended with a fatal outcome. The definition of intimidation is

intentional behavior that "would cause a person of ordinary sensibilities" to fear injury or harm. 

This related to some answers my sister, a registered nurse at the Orlando Health Regional

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Medical Center, gave to me during our interview. She also brought up the experience she’s felt

with being “afraid of asking” because as a nurse, some doctors “​expect you to know what you

are doing​.” ​For every medical workplace, there should be ways to help break that intimidation

barrier because if it is not addressed, it could potentially lead to a bad outcome. Nurses or

medical assistants should be encouraged by their peers or providers to speak up if they see

something.

Conclusion

As my research came to an end, It was clear that there is still a need for improvements of

clinical documentation. It is an ongoing cycle of improvement for providers, assistants, and

nurses. A challenge I faced in my research was collecting my primary research. My data

collection was very limited because of the precautions of the pandemic. It was hard to conduct

multiple interviews with many different healthcare providers, but the interview with my sister

gave me an insight to clinical documentation. If I were to improve my research, I would conduct

more interviews next time. Although I faced some limitations, my research shows that many

ways clinical documentation can be improved is through clinical documentation workshops,

addressing intimidation within a workplace, and increasing communication within the

communities of nurses and doctors. At the end, the main goal of most healthcare workers is to be

able to provide the best healthcare service. We want to be able to evaluate, assess, plan,

implement, and treat patients.

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 Works Cited

Collins, Sarah, et al. “Quantifying and Visualizing Nursing Flowsheet Documentation

Burden in Acute and Critical Care.” ​AMIA ... Annual Symposium Proceedings.

AMIA Symposium​, American Medical Informatics Association, 5 Dec. 2018,

www.ncbi.nlm.nih.gov/pmc/articles/PMC6371331/.

Dehghan, Mahlegha, et al. “Quality Improvement in Clinical Documentation: Does

Clinical Governance Work?” ​Journal of Multidisciplinary Healthcare,​ 2013, p.

441., doi:10.2147/jmdh.s53252.

Forshee, Alexus. “A Genre Analysis of Patient Notes and Documentation Practices in the

ICU .” Writingandrhetoric.cah.ucf.edu, 2018,

writingandrhetoric.cah.ucf.edu/wp-content/uploads/sites/17/2019/10/stylus_10_1_

Forshe e.pdf.GSK group of companies. “Creating Order Sets to Include Patient

Education in e-MDs EHR .” ​Gskpro​, 2017,

gskpro.com/content/dam/global/hcpportal/en_US/pdf/ehr-resources/eMDs/orderse

ts.pdf.

Iyer, Patricia. “Documentation: Avoiding the Pitfalls.” ​Youtube,​ 2009, Documentation:

Avoiding the Pitfalls.

Russo, Ruthan, et al. ​Improving Physician Clinical Documentation Quality: Evaluating

Two Self-Efficacy-Based Training Programs​. 2013,

downloads.lww.com/wolterskluwer_vitalstream_com/journal_library/hmr_03616

274_2013_38_1_29.pdf.

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Wardle, Elizabeth. ​Writing about Writing.​ Bedford Books St. Martin's, 2020.

Appendix

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Citi Training

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Transcript of my interview

Me: To start off the interview, Based on a scale of 1-10, 1 being the lowest and 10 being
the highest. How would you rate your clinical documentation skill?

Interviewee: I would give me skills a 7- Only because I have been working for less than a
year. There is definitely a lot I need to learn, like coding and documenting patient’s
information. Clinical documentation skill is definitely sometime that everyone like
myself learns to improve every single day. There is no doubt that it is a crucial part of my
job. For example,If a patient is showing symptoms or changing condition, it is important
to document that. Not only is it important to us nurses but also for others like physicians
and other doctors.

Me: Wow, I find that very relatable with my works in an outpatient clinic as well. Has
there ever been a time where you struggled with clinical documentation?

Interviewee: Absolutely. When doctors are clear with their notes, it can be hard as a nurse
to go about a patient. I have to understand what is this patient's condition, their past
medical history, what medication they are taking, and most importantly why they are
there.

Me: It’s so crazy how I used to think what nursing was but there is absolutely more than
what I thought. Based on your experience do you believe you need more clinical
documentation practice and knowledge?

Interviewee: Yes I do believe I need more training in clinical documentation because I

feel like it is something that is always changing. Coding can be tricky sometimes because
that deals on the side of health insurance and part of a patient’s chart.

Me: Could you specify what you mean by coding and insurance?

Interviewee: Sure! So with insurance, if the provider does not document the right code
for a patient’s condition, the patient is at risk to be left with a bill. Another example
where coding can be tricky with a patient’s chart is if it is not documented right, other
nurses can be left with wrong information about a patient, or if a condition is not
documented, it is hard to understand the patient as well.

Me: You kind of answered my next question but what is one struggle with clinical
documentation?

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Interviewee: Learning how to code correctly for a patient's condition but also
highlighting every step of a patient's condition. It is hard for patients that have a lot of
medical problems but it is important to keep track. If anything ever happens to a patient,
doctors/providers will be able to assess what the problem is from or what could have
caused it.

Me: I find it interesting how each and everything problem had to be documented. When
there are mistakes or errors, I see how that can be challenging. My research is to learn
how clinical documentation can be improved. So how do you think clinical
documentation can be improved?

Interviewee: I believe that offering clinical documentation workshops/programs for all

healthcare workers can help improve clinical documentation. Many hospitals have
clinical documentation specialists of their own but it is also important for many different
providers to have skills with documentation. Hospitals that are able to provide these types
of workshops would ultimately help their workers.

Me: Workshops and programs are definitely a step towards improvement but I also
believe through every step, communication amongst doctors, nurses, and healthcare
providers is the most important in clinical documentation.

Interviewee: Most definitely! At the end of the day, my job is to provide the best care to
my patients and with that, clinical documentation is a big chunk of my job. Another
aspect of clinical documentation that many nurses like me can relate to is feeling afraid to
ask for clarification. I am still new to my job but intimidation is very common with new
nurses because other people expect you to know what you are doing. There needs to be a
way to break that barrier of intimidation. I’ve been given a doctor’s note for what
medication and dosage a patient needs but it can be hard to read. “Doctor’s handwriting”
is another challenge because even though I should not feel afraid, I sometimes get afraid
of asking. The unit I work in the hospital, everyone is not really close knit which is fine
but hopefully I will lose that fear of intimidation but it is the reality of many nurses.

Me: Before we close off the interview, just wanted to say thank you for taking the time
out of your day to give me an insight of how clinical documentation affects you and your
job as a registered nurse. With that being said, you can agree with me as well. What I’ve
taken from this is that there is the need to improve clinical documentation for sure.
Consent Form

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Consent Form
I ,________Tammy Van__________________ , [NAME OF INTERVIEWEE] am consenting to
participate in an interview/survey [SELECT WHICH ONE] about
______Interview____________.

Which is being conducted by ____Ellenia Van_________ [YOUR NAME] for ENC 1102 at the
University of Central Florida with ________Sara Thames__________ [PROFESSOR’S
NAME].

My participation is voluntary, and I understand that I can discontinue the study at any time. I
understand that I am also free to withdraw from the study after the interview has been completed
without penalty.

I understand that I will not be paid for my participation.

I understand that this study may pose the following risks to me:
[THERE ARE ALWAYS RISKS, EVEN IF IT IS MILD DISCOMFORT]

I understand that I may decline to answer questions which make me uncomfortable.

The researcher anticipates that this research will take _____10-15 minutes______[FILL IN THE
ANITICIPATED TIME] of your time.

If I do not wish for the researcher to record or keep/use my answers, I understand that I will not
be able to participate in the study.

I understand that I have the right to ask that the researcher not identify me by name and that I
have the right to remain anonymous if I wish to remain so.

I understand that this study has not been reviewed by UCF’s IRB.

I am over 18 and I have read and understand the statements above and consent to participate in
the study.

_________________Tammy Van_________________________(signature)

______________________10/18/2020____________________(date)

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____________________Ellenia Van______________________(principal researcher)

EMDs Template

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https://ga1.imgix.net/screenshot/o/103579-e-mds-solution-series-1461729487-9939141?ixlib=rb-
1.0.0&ch=Width%2CDPR&auto=format

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