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Document Standardization: Better Care

June 21, 2017

Standardization must play a significant role in our healthcare system. It will help optimize efficiency, communication, and quality of care.


Mrs. Jay, 83-years old, is a patient with a known history of significant reaction to nonsteroidal anti-inflammatory drugs (NSAIDs). An allergy to acetylsalicylic acid was documented in the patient’s paper chart, but this information was not captured in the electronic health record used by the healthcare team. In paper charts, information noted only once will get buried under the noise of frequent vital assessments, making this documented allergy information hard to access by the healthcare team. It’s completely left to chance whether Mrs. Jay’s treatment results in a fatal allergic reaction.


How could such costly communication breakdowns be avoided?

While personal health information and healthcare provider notes are unique to each patient, the way in which the information is documented can be captured in a much more consistent way. Streamlining this process will allow clinicians to reap the powerful benefits associated with standardization.

Despite this, standardization is yet to be fully implemented. There is currently no consensus on what should be documented, and as such, clinicians essentially develop their own style of documentation. The significant variability in the way clinicians document, as well as the prevalence of illegible and disorganized notes, create documentation that is difficult to understand.

Obstacles to documentation

Undoubtedly, there are hurdles to overcome when implementing a standardization method. Health care organizations don’t set hard requirement for how information is documented in the patient record – they set guidelines for the right information to be present in the patient record. This lenient stance and lack of regulation doesn’t encourage healthcare providers to change their approach to documentation.

Furthermore, current practice in documentation is heavily ingrained in clinician workflow which differs from profession to profession as well as unit to unit.  ‘One form to win them all’ is a hard concept for clinicians to embrace, because culturally, each physician and nurse document for different reasons. For example, nurses document to provide a record of the care provided as well as patients vitals, while physicians document using the medical model to provide evidence for their chosen plan of care.

Tracking for success

Overcoming these hurdles of creating a standardized process is necessary and will ultimately advance the healthcare system. One key benefit is increased efficiency, as the predictability of the information layout translates into a more efficient workflow. Consistent formatting and prepared templates results in faster information retrieval and documentation. Once familiarized with the system, clinicians can use the time saved from documenting and transmitting information from scratch to help and treat patients

Communication within a healthcare facility is also strengthened from standardization. With time, documentation will be more comprehensive through utilizing evidence based documentation and having a higher level of completeness. The ability to transmit these well-crafted notes quickly gives all of those within the circle of care access to the most up-to-date and accurate information, allowing each unit to provide the highest quality of care.

Moreover, the standard modular format of standardized notes can be mapped to create data and dashboards, permitting healthcare facilities to make decisions based on analysis. For example, administrators could use the data generated from standardized notes to assess the most effective resource allocation per unit.

Document standardization must be a higher priority by healthcare organizations to make a difference. Management must emphasize the reliance on a mutual method of documentation with predefined information standards – such as the degree of detail required – to strengthen workflows and ultimately deliver the best care possible to at-risk patients like Mrs. Jay.

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