In a crucial sector like healthcare mistakes and errors are unacceptable, as it deals with restoration of health. Documentation of practices followed to supposedly restore heath, is made in, what used to be called ‘patient files’, which was later christened ‘Electronic Medical Records’ (EMR).

Documentation helps in more ways than one in healthcare industry;

  • Communicates with other healthcare personnel

Documentation communicates the details of clinical care being delivered to patients, and serves to facilitate continuum of care among rungs of healthcare providers.

  • Reduces risk management exposure  

Documentation mitigates risks and chances of malpractice.

  • A well-documented record helps alleviate liability concerns in the event of a claim.
  • Records Hospital Quality Indicators

Documentation captures value-based purchasing metrics that, increasingly the government is asking hospitals to provide. These include Hospital Quality Indicators and PQRS-Physician Quality Reporting System Measures (which addresses various aspects of care viz; prevention, chronic and acute care management, procedure- related care, resource utilization and care coordination).

  • Ensures appropriate reimbursement

A well documented medical record facilitates revenue cycle processes, expedites payment, and reduces hassles associated with claims processing and reimbursement.

An ideal document narrates the patient’s ‘story’- the presenting problem and treatment received, which helps to plan and evaluate a patient’s treatment. It creates a permanent record for future care, and builds a data base useful in research and education. It serves as a crucial document in litigations. As the saying goes, ‘if you didn’t document it, you didn’t do it’.

Precise Documentation in healthcare is made on the patient file, or on the EMR at distinct points of care viz;(1) during admission, where details of presenting symptoms, clinical findings, and preliminary tests, basic or advanced, are recorded. (2) During the course of hospitalization where recordings during rounds, clinical discussions relevant to patient care, details of procedures, major and minor, with or without the use of anesthesia, consent for the above, administration of blood and blood products, and drug prescriptions, and reasons for the same are documented.(3)course after, and during treatment viz; discharge, referral to a higher centers for more specialized care,  or to low-end centers, for basic monitoring or basic care, meant to cut costs, or for palliative end-of-life care, discharge requested by patients against medical advice, or other reasons. In these situations, documents accurately detailing the patient’s diagnosis, response to treatment, procedures, surgical or otherwise undertaken are issued to the patient in the form of a discharge summary, referral letter, or relevant certificates.

An important aspect of healthcare such as documentation fell into wrong hands of hospital administrators, especially those of profit-interested corporate behemoths, supplemented with accreditation by various agencies, national and international. Accredited Healthcare facilities are theoretically more adept at dispensing quality healthcare, thanks to stringent standards demanded by accrediting agencies. Accredited hospitals are much sought-after by so-called ‘health tourists’.

 Accreditation signages on hospital hoardings had their salability furthered among consumers seeking the fad of the times- ‘health tourism’, which hospital administrators came to be interested in. For obvious reasons. They ensured uncompromised adherence to documentation, which took on exaggerated proportions. Paper work among healthcare personnel made gargantuan leap. Doctors, and particularly nurses became ‘white-coated’ clerks within hospitals, where patient files and EMR are given preference over patients. Patient files gained in ‘nourishment’ with more forms, some of them irrelevant, or even absurd and insignificant to patient care. Increasingly patients were left to fend for themselves even in care-heavy areas of hospitals like ICUs and HDUs. Nurses, instead of being beside sick patients came to be huddled over sheaves of paper, irrelevant registers and computer keyboards. Nurses and doctors distanced themselves from patients, who were denied the crucial human touch and presence at a time of healthcare induced stress and emotional vulnerability, such as in the loneliness within ICUs, compounded by fear caused by monitor alarms and moanings of other admitted patients.

Parameters that ideally merit documentation viz nurse: patient ratio, time healthcare personnel spend with patients were sidestepped or even lied on conveniently, or even swept under the carpet.  Patients who survived or were cured of their ailments did so on the strength of their lucky stars. Paperwork became a distraction during rounds. Doctors had their concentration high jacked from patients to their files, adding to paperwork on a habitually understaffed sector. Plainly speaking, patients are left to fend for themselves within hospitals. Accreditation auditors add more forms and documentation added files with every visit. Hospitals were interested in pleasing them than patients admitted seeking healthcare from them.

Is there a way out?

  • Documentation must be deescalated to basic essential ones that impact patient care.
  • Accreditation auditors must visit hospitals unannounced, much unlike school inspections. allowing schools enough time to spruce themselves up! To gauge the true goings-on within healthcare facilities.
  • Hospitals can employ science graduates or educated hospital assistants to spare healthcare personnel from unnecessary documentation, to utilize time gained for more important and relevant aspects of patient care.
  • Quality Indicators must closely reflect what goes on within hospitals, and those more relevant to healthcare dispensation, like nurse: patient ratio, job satisfaction among various healthcare workers, which hospital administrators would prefer to ignore.  
  • Government and watchdogs of healthcare like the now defunct IMC, and IMA must confer patient feedback of individual hospitals due attention.
  • Auditors visiting hospitals to bestow accreditation must be those pursuing active clinical practice, and not retired professionals, removed from realities within healthcare centers of the times, or those belonging to non-clinical specialties.   
  • Priority must be shifted from ‘health tourism’ to ‘health to natives’, at affordable costs and basic humaneness.
  • Healthcare must be is rescued from stranglehold of over-corporatization and profit-making.