At a recent conference I attended in Birmingham,AL where I was hosting an open door discussion on Clinical Documentation Best Practices, I posed the question to a group of physicians what constitutes complete, accurate and effective clinical documentation. This opened up a lively discussion that started with there is no such thing as effective clinical documentation given the fact third party payers change the rules and can interpret documentation anyway they want to and not paid the provider. The discussion continued for 15 to 20 minutes and the general consensus was effective documentation consists of concise,, accurate and up-to-date clinical information in the chart outlining what is happening with the patient, what is the physician thinking in terms of diagnoses and why and where is the physician going in terms of plan of care including further workup, treatment and diagnoses provisions.

An important aspect of documentation that needs to be raised and reinforced is medical record documentation does not serve only as a means for coding, billing and payment by third party payers. Clinical documentation’s main purpose is to serve as a communication tool for patient care and continuous quality improvement outcomes. The record provides a foundation for physicians to record patient care including clinical reasoning, judgment, medical decision making, thought processes and problem solving ability associated with patient care. A complete and accurate medical record promotes better patient care,  better quality outcomes, better care coordination, better physician and hospital profiling, better resource utilization, and better results in the value=quality/outcomes equation. Compare this viewpoint of accurate and complete documentation in an article recently released and posted February 18th on Cahaba GBA’s website, a Medicare Administrative Contractor, titled “Documentation Points for Accurate Medical Records.” The following is labeled as Standard Content of the Record:

  • The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services.
  • Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient
  • Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia
  • All practitioner s’ orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition
  • Discharge summary with outcome of hospitalization, disposition of care, and provisions for follow-up care
  • Final diagnosis with completion of medical records within 30 days following discharge
  • The record must support reasonable and medically necessary services and provide an accurate account of all patient care services provided by healthcare professionals.

Bridging the Gap

Physicians went into medicine to take care of patients the best way they know how, one patient at a time. Effective and complete clinical documentation is often times viewed as difficult, time consuming and challenging, particularly in light of the structured format and content of the electronic health record. How best to bridge the gap of the practice of medicine and the reporting of value performance based cost effective medicine in the record. Rather than focus on each individual standard element of record content, instead focus upon the eight principles of effective clinical documentation. By doing so, physicians can relate and ascribe to Sir William Osler’s recognition of the medical record, that is to observe, record, tabulate and communicate- used by physicians to record their findings and actions and communicate with other physicians who might care for the patient in the future.

The eight principles of effective physician clinical documentation include the following:

No change in the physician’s practice of medicine


Physician Focus upon capturing:



  • Where has the patient been
  • Where is the patient now
  • What are you thinking
  • Why you thinking
  • Where are you going and why
  • What did you find when you got there
  • What actions did you take, what actions are still needed and how long is it going to take
  • What actions remain for post-acute care


By getting back to the basics of medicine and documentation using the eight principles of effective physician clinical documentation, all the necessary components of an effective, concise and complete medical record will be incorporated as outlined above. Effective documentation can be achieved in less time, be more intuitive to the physician, and less of a hassle and challenge as physicians perceive with the heightened regulatory and documentation billing requirements associated with the practice of medicine.