Adequate clinical documentation is a vital component of a successful continuum of care
There are few industries in which precision is more essential than healthcare. From diagnosis to care delivery, meticulousness and accuracy are critical to achieving successful patient outcomes. Yet, regardless of their condition, most patients will encounter myriad providers, specialists, and staff throughout their medical journey—and with that comes a risk of jumbled documentation.
With so many different healthcare professionals in a patient’s life, adequate clinical documentation is a vital component of a successful continuum of care. And that’s especially true for pain management practices that must carefully straddle a fine line between appropriately treating patients’ pain and accusations by non-medical regulators of contributing to opioid addiction and misuse.
Why is clinical documentation so important for pain management practices?
Keeping satisfactory clinical documentation is one of the most effective ways to ensure patients receive the best possible care and that physicians can defend that care.
A good rule of thumb is that any doctor reviewing a patient’s clinical record should feel they have enough historical information to be comfortable administering appropriate care. The medical record should tell a story for anyone reviewing the record to understand the thought processes of the provider and the rationale for the care provided. Failing to keep medical documentation at an appropriate level can lead to subpar patient outcomes and may leave the provider or practice vulnerable to legal complications. (For more on the requirements governing pain management practices and their use of opioids, please read this perspective from our Chief Medical Officer Dr. Lynn Webster.)
Additionally, pain is a subjective sensation. While some describe shooting or stabbing pain, others endure dull or constant aches—and the treatment options used to treat those symptoms can differ based on what, where and how the patient describes the pain among other considerations. This is why documentation needs to also include direct testimony from the patient themselves, in their own words, describing their experiences.
As thoracic surgeon Dr. Samer Kanaan notes, "documentation is legal protection for both patient and physician" and should provide a clear and easy-to-follow rationale for care on both sides.
Sound clinical documentation means going beyond the SOAP note
While “SOAP notes” (an acronym that stands for subjective, objective, assessment, and plan) have been the historical standard for documentation, more healthcare providers are now urging their colleagues to go beyond the traditional SOAP note.
As described by one physician, SOAP should actually be SOOOAAP, or subjective, objective, opinion, options, advice, and agreed plan.
There are several points within SOOOAAP notes that can be critically important. For instance, providers and staff should document direct patient quotes and their expected treatment goals, including time frame, while avoiding judgmental descriptions. Patient comments provide an important context to decision making that are rarely documented. As the medical record belongs to the patient, it’s in the provider’s best interest to steer clear of any extraneous documentation that could lead to friction.
While it’s critical to be accurate and precise with clinical documentation, good clinical documentation must also be clear, consistent, thorough, logical and timely.
Examples of clinical documentation for pain management practices
For pain management practices specifically, providers should be documenting a baseline risk assessment, along with other required elements like diagnostic, therapeutic, and lab results. Proof of discussing risks and benefits of any treatment is essential. Documentation should also include notes on follow-ups, the frequency of visits, physical exams, and type and frequency medication prescribed without an office visit and the thought processes that support the providers decision making.
In an article written for Practical Pain Management, one physician recommended that pain management practices document the 5 A’s on follow-ups:
Without these details, a chart may be considered incomplete or inadequate, potentially leading to poor outcomes and potential legal concerns.
We understand the importance of proper clinical documentation. The PainScript platform is a digital evaluation and management approach that pain management practices can use to help improve patient adherence to medication and care plans. Our solution empowers providers to gather and archive daily patient documentation in real time, contributing to the care continuum.
To learn more about how PainScript can help your practice, request a demo.
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