What is Clinical Documentation in Healthcare?

In this micro-lecture, we discuss clinical documentation for Paramedics and its importance.  Enrolled students have unlimited access to a rich library of learning materials such as this.

In this micro-lecture, we’re going to talk about the importance of clinical documentation of providing evidence on a patient care record. So everything that you do, as a paramedic, when it involves treating another human being, must be documented appropriately, professionally, in a timely manner, in a manner that is legible, readable and the information that you provide on that patient care record really does provide a basis for the summary of the care that you have provided to that patient.

Anything you document will be stored for, I’ve heard figures from 10 to 20 years, and, in fact, myself, moving through the system, when I was a student, I remember going to a patient under the supervision of a mentor and then five years later, being asked to give evidence in a court of law about a situation.

So anything you document really should accurately reflect what happened, and you need to really be providing as much information as possible on your patient care records.

Now, when you’re writing your patient care records, it’s a skill that you’re going to develop over many years. You know, we have students in the workshop and they have to provide patient care records for their cases that they’ve attended to in the simulated environment, and they struggle with providing a patient care record because they think that it’s an easy task, and really, it isn’t.

I remember, in my experiences, it does take you quite a little bit of time to become expert at knowing what to write, how to write it, where to write it, knowing when to stop writing, knowing if you need a continuation sheet to provide more evidence, and you tend to get this kind of sixth sense for those cases that you know are going to end up in coroner’s court, and therefore, you end up with having to write your extra testimonials to provide that evidence.

So, the other thing you have to remember is that if you didn’t document something, then it didn’t happen. In other words, if you’ve gone to a patient and let’s say you’ve done a blood sugar level and treated that patient with hypoglycemic agents, but you forgot to document either of those things, then in a court of law, it actually didn’t happen.

And the judge can be stood in front of you and say, “Look, why didn’t you treat them for low blood sugar?” “Well, I did.” “Well, no, you didn’t,” says. So, regardless of whether or not you say you did, it actually didn’t if it was not documented.

The other thing you have to mention is if you’re writing about the situation that you’ve got in front of you or that you’ve just had, because there are occasions when you wouldn’t even touch the patient care record, if the patient’s critically unwell, for example, you really do need to be stepping back and treating your patient, and then you’ve got to rely on your memory in case, or maybe you made some notes.

There’s a couple of things you can do.

You’ve got to make sure that what you’re writing is accurate and factual. Make sure that you’re filling in all the boxes because if you haven’t filled in all the little boxes, in a court of law or to your managers who are monitoring your patient care records, it might look like you’re not actually caring too much about what you’re doing.

It looks like there’s gaps in your care, even though you know that there isn’t and so do the people who are looking at that. But, to anybody else outside who’ve got access to that, it might look like you haven’t taken it seriously.

So there’s little things you can do, like if there’s a box that’s not relevant to you, you can cross through it and put “not applicable” or “not relevant,” something like that. And, of course, usually, your ambulance service will provide you guidelines on that.

Okay, so that’s just a micro-lecture on patient care records and clinical documentation. My name’s Sam Willis and I hope you enjoyed it.

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