Great documentation is going to be key during these uncertain times of COVID-19. For any clinician who has gone through an audit, chances are their auditors have said “tell me a good story” more than once during the process.
Telling a good story is so important and often times even something that seems obvious to the clinician and trivial to include in a note can leave out vital information.
Here is one example that was given by NHPCO during one of their webinars; Telehealth visits for this patient to protect patients and caregivers from illness, due to global pandemic, national state of emergency, and shortage of uninfected nurses. I spoke with this patient and his wife via telehealth. Inspection of wound and information from family shows that there has been a decrease in redness on the heels, pain maintained at 2/10 with current regimen……no in-person visit required at this time, will check in via telehealth in 48 hours, the family has instructions for crisis contact 24/7. This example checks so many boxes and in just 2 short sentences it completely sets the scene for what to expect from the encounter. It outlines the limitations of care and why it was important to have a telehealth visit with this patient.
What statements are your clinicians using during this time?