Dynamics of
Care in Society
Written Communication
&
Medical Documentation
1
Written communication
“practical writing”… for a specific purpose,
ex:
 Reports
 Business letters
 Interoffice memos
 Manuals
 Forms
 Applications
 Chart documentation
“Practical Writing” Types
 Narrative writing…tells what happened, paragraph
form,
 Descriptive writing…details of person, object, event
 Informative writing…giving directions, explaining how
to, answering questions, making something easier to
understand, use bullets or steps,
 Persuasive writing..giving an opinion or stating a point
of view and supporting it with reasons in order to
persuade the reader to accept or possibly take action
on it
Recording and Reporting
 Record patient information completely &
precisely
 Record information only in secure &
appropriate locations
 Record any action you take concerning a
patient (“if it is not documented…it didn’t
happen”)
 Just the facts…
 Minimize medical jargon (if for a patient)
Drafting hints…
 Get started… get comfortable, be concise, have logical
transitions of thought
 Outline ideas… organize before you write
* brainstorm
* group similar ideas together
* find unifying themes
* have a beginning, middle, end
 Revising…check for…
* clarity
* sentence & paragraph structure
 Proofreading… refinement…check for…
* grammar, punctuation, spelling
* final touches
Tips for… “Well & Clearly Written”
- create an outline to clarify and order your concepts
- write a really bad first draft with no rewriting
- rewrite, read out loud, rewrite, read again and rewrite
- have colleagues comment on your draft
- trust feedback from reviewers and rewrite again
- let it sit, return for a fresh read out loud, and finalize
Ideas for Learning to Write Better
• Read examples you like and also review your colleague’s
draft papers and edit them.
• Take course in essay writing - good analysis, clear
arguments and exposition, and convincing conclusions.
• Write for broad audiences too - if you can capture them,
you can capture professionals
• Read your writing out loud and then edit!
For Research Assistance…
UCLA Library
under services menu tab choose
references & research help
MEDICAL
DOCUMENTATION
Purposes of documentation in HC
1. Communication among the health care team
2. Assessment (vital signs, hx, symptoms…)
3. Quality Assurance (competence & quality of care)
4. Reimbursement (verification for insurances…)
5. Legal Record (admission of evidence)
6. Education (use for training)
7. Research: Useful Data Gained From Patient Records
 Examples:
Nurse updates patient’s record with new info from patient
Doctor sees nurse’s note & orders cholesterol test
Pharmacist views medical history before filling prescription
Discharge planner evaluates physical therapist’s notes on
progress in ambulation
(note the communication process w/in the medical record)
Electronic Medical Records are here…
Advantages of Computerized Documentation
 Ease of access to data
Multiple users simultaneously
 Different locations
 Various devices
 Easy storage & retrieval; faster recording of data
 Nearly unlimited file space
 Easy back-up for security
 Easy to add or attach info
 Improved legibility

Safe Computer Recordkeeping
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Don’t share passwords/computer signature
Don’t leave logged-on terminal unattended
Follow protocol for correcting errors
Allow only authorized personnel to create, change, or delete
files
Back up records regularly
Don’t leave patient info displayed on monitor in view of
others
Keep running log of electronic copies made of files
Never use unencrypted email to send protected health info
Follow confidentiality procedures for sensitive material
What you’ll find in the medical record…
Admission sheet – general demographic info, insurance info…
Graphic sheet – aka Flow sheet - for vital signs…
MD orders – for medications, instructions, procedures…
Progress notes – on patient’s progress, new or changing info
from multiple health care team members
Medical history and exam –
"Listen to your patient, he is telling you the diagnosis," Sir William Osler, M.D
Johns Hopkins
Allergies, Immunizations, Childhood diseases
Current & past medications
Previous illnesses, Surgeries, Hospitalizations
Family medical history
Reports – test results, lab results, consultations…
Psycho-Social History
Marital status
Occupation
Education
Hobbies
Diet
Alcohol, drug & tobacco use/misuse
Sexual history
Miscellaneous – correspondence, AD, organ donor…
Good Medical Documentation Tips
1.It is accurate (ex. Correct spelling, Errors marked
through, labeled with “error,” initialed, & dated…)
2.It is complete (ex. All supporting information –
lab results …)
3.It is concise (ex. Only relevant information), just
the facts
4.It is legible
5.It is organized (ex. Most recent information first,
date stamped…)
6. It is signed, initialed, dated and/or timed *– as
required
See article about accurate documentation
Progress Notes --- 3 Types
1. SOAP notes
Subjective data
Statements from patient describing condition
Symptoms experienced
Objective data
Data that provider can measure, see, feel, or smell
Test results
Vital signs
Assessment
Patient’s diagnosis
Possible disorders to be ruled out
Plan
Description of what should be done
Diagnostic tests
Treatments
Follow-up
2. Charting by exception
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Covers only significant or abnormal findings
Decreased charting time
Greater emphasis on significant data
Easy retrieval of significant data
Timely bedside charting
Standardized assessment
Greater interdisciplinary communication
Better tracking of important patient responses
More cost effective
3. Narrative
 Paragraph format
 Includes:
Contact with patient
What was done for patient
Outcomes
 Can be time-consuming to write & difficult to
read
 It is the oldest & least structured type
Handout…
PROPER TELEPHONE COMMUNICATION
ANSWERING….
1. ANSWER PROMPTLY
2. IDENTIFY SELF
3. FIND OUT WHO IS CALLING
4.SPEAK COURTEOUSLY, CLEARLY & PLEASANTLY
5. USE DISCRETION IN RELEASING INFORMATION,
REMEMBER CONFIDENTIALITY
6. END CALL GRACEFULLY
Handout… SCREENING….
1. DON’T OFFEND CALLER
2. ASK WHO IS CALLING, NATURE OF
BUSINESS OR EMERGENCY
3. ANSWER QUESTIONS TACTFULLY
4.ASK IF MESSAGE CAN BE LEFT
5. PLACE ON HOLD AND GET GUIDANCE, HELP
IF NEEDED
Handout…
TAKING A MESSAGE….
1. OBTAIN TIME, DATE, NAME OF CALLER ,
PURPOSE OF CALL
2. TAKE NOTES, REPEAT INFO BACK TO CALLER
FOR ACCURACY
3. USE MESSAGE FORMS & FOLLOW THOUGH
WITH PASSING MESSAGE TO CORRECT
RECIPIENT.
Handout…
HANDLING COMPLAINTS….
1. STAY CALM
2. GATHER INFO
3. BE SYMPATHETIC
4.OFFER TO FIND OUT
WHAT CAN BE DONE
5. END CALL ON PLEASANT
NOTE
Handout…
Assign:
What is the message for each?