Using a standardized format for your documentation can help you organize your information, ensure consistency and completeness, and avoid duplication or omission of important details. It also makes it easier for other professionals, agencies, or auditors to review and understand your documentation. Depending on the setting and scope of practice, you may need to follow specific guidelines or templates such as SOAP (Subjective, Objective, Assessment, Plan), PIE (Problem, Intervention, Evaluation), or DAP (Data, Assessment, Plan). If you have some flexibility in choosing a format, select one that suits your style and preferences while still covering the essential elements of patient assessment and care plan. Such elements include identifying information (name, date of birth, case number, contact details etc.), presenting problem (reason for referral or service, main concerns etc.), assessment (findings of assessment including patient’s strengths, needs etc.), care plan (interventions agreed to undertake etc.), progress notes (updates on patient’s status etc.) and evaluation (summary of patient’s progress etc.).
Being clear and concise means using simple, direct, and accurate language to convey your information without unnecessary words, jargon, or ambiguity. This can help save time and space, avoid confusion or misunderstanding, and enhance the credibility and professionalism of your documentation. To achieve this goal, use active voice instead of passive voice; use specific and descriptive words instead of vague or general words; use short and simple sentences instead of long and complex ones; use bullet points or lists when appropriate; and only use abbreviations or acronyms when they are commonly known or defined in your documentation.
Reviewing and revising your documentation is an important step to ensure its quality, accuracy, and completeness. You should review and revise your documentation before you submit or share it with anyone else, as well as periodically to update or modify it as needed. To help you review and revise your documentation, be sure to check your spelling, grammar, punctuation, formatting, facts, data, sources, tone and style for any mistakes or typos. Additionally, check your content and structure for any irrelevant, redundant or missing information; as well as references and citations for any plagiarism or copyright issues. Documentation is a key component of case management services that reflects your professional judgment, skills and standards; thus following these tips and best practices can document patient assessments and care plans in a clear and concise way that supports your practice and enhances outcomes.
When documenting anything about a client, I think it’s also incredibly important to consider the connotations of your words. Coworkers, management, or the client themselves may read the documentation, and using words like ‘clean’, ‘non-compliant’, ‘attention seeking’, or even ‘refused’ in certain circumstances can paint the client in a certain light.