How to write an effective clinical document?

Medical records are the most important practice tools used by doctors in their daily practice, regardless of specialty. The rule of thumb is “If it is not documented, it does not exist.” Deficiencies in the clinical documentation have been directly linked to increased incidence of adverse events and medical errors with resulting patient injury. Doctors are required to keep accurate and comprehensive medical records that will stand alone without their interpretation. An excellent medical record should be clear, concise, complete, accurate, and current factual record of clinical care. That must be recorded in a legible chronological and a confidential way while avoiding duplications and abbreviations. Written communication is vital to patients' quality of care, and thus this paper is dedicated to the basic written communication skills and concepts that are foundational to all healthcare professionals. In this practice point, we provide standardized templates for most common written documentation by physicians.

Key-words:

Documentation - medical records - progress notes - written communication

Publication History

Article published online:
07 July 2022