EHR documentation is a pretty broad term for something so integral to the success of any provider’s platform and process.
In the most simple terms, documentation consists of the EHR functions and tools used to document information about a patient. Within that umbrella definition there is considerable variety among the different types of documentation.
When speaking to clients about documentation, we like to break it down into 4 classifications:
- Progress Notes
- Treatment Plans
Read on as we explore each classification in depth. These distinctions are important to understand and consider when searching for a software solution for your organization.
Think of forms as documentation used to collect non-medical information, such as:
- Consent forms
- Releases of authorization
- Releases of information
- HIPAA authorizations
Forms are these types of administrative documentation, typically something you would need to get a patient signature on.
2) Progress Notes
One of the most frequent questions we get during user training or demos is: “what’s the difference between a form and a progress note?”
Of course, you already know that forms are the non-medical documents that facilitate the administrative aspects of a patient’s treatment.
A progress note, on the other hand, is medical or clinical in nature. It is a critical documentation feature of any EHR that records information relative to a patient’s ongoing treatment.
In other words, progress notes are where providers document a patient’s treatment updates.
Since every patient’s life cycle is unique, every progress note is going to look a little different. As a result, an EHR should allow providers to document a wide range of data in their progress note templates.
This is especially important to the behavioral health and addiction treatment organizations we serve. Their patients often pass through multiple levels of care. To deliver safe and up-to-date treatment, there shouldn’t be any treatment development that a progress note cannot document.
Your EHR’s progress notes should offer the flexibility to include everything from a therapist’s notes based on a face to face session or a new diagnosis to lab result analysis or a summary of a telehealth appointment.
Another important feature for our behavioral health and addiction providers is the group note, which should essentially act as a progress note for group sessions. The most functional EHRs allow for integration between progress notes and group notes so that any relevant individual updates from a group session can be documented on each patient’s progress note.
Assessments can serve a variety of documentation purposes.
To keep it simple, there are two types of assessments:
- Those used for general data collection
- Those used as an active treatment tool
A perfect example of an assessment used for basic data collection is an intake assessment. These are the documents you fill out when you go to the doctor that collect your medical history, do you smoke or drink, your current medications, and so on.
In that way, this first type of assessment gathers the necessary background information of a patient to begin safe and informed treatment.
The second type of assessment is associated with outcomes. These are scored assessments that collect actionable data about a patient’s treatment, such as:
- CIWA and COWS for tracking withdrawals
- ASI or Recovery Capital Scale for addiction treatment
- The Beck Anxiety Inventory for behavioral health treatment
All of these examples are comprehensive assessments designed to track a patient’s treatment progress. Doctors and clinicians rely heavily on scored assessments to provide past and current snapshots of a patient’s health so that their care can be adjusted as necessary.
Other scored assessments gather data that is not directly linked to a patient’s treatment, such as a client feedback survey.
Typically administered through a patient portal, these surveys collect information regarding patients’ satisfaction with the treatment they received. These types of assessments are very useful quality assurance tools that can uncover shortcomings and inspire improvements in your process.
4) Treatment Plans
This is perhaps the most self-explanatory one of the four. A treatment plan is quite literally a plan for each patient’s treatment.
Think of it as an outline of how a provider intends to care for a patient. This is a document where providers can establish both short and long term goals so that each patient’s care is comprehensive and individualized.
Though terminology and comprehensiveness may vary depending on the organization, treatment plans are quite standard documentation across the industry.
Generally, they follow the same basic “Problem Set” template:
- Problem: The problem or obstacle the patient needs to overcome in treatment
- Goal: The short term efforts the patient will make to address the problem
- Objective: The long term treatment outcome we want to achieve
- Intervention: The efforts the patient will make to achieve the objective
Further EHR Education
We hope you have a better idea of what EHR vendors mean when we talk about documentation. Though it may seem pretty basic, documentation tools are a foundational element to the EHR experience. They have the potential to optimize or hinder your operation.
To help you identify quality documentation tools, take a look at this deep dive we did on progress notes. We discuss the two most critical progress notes features that promote positive outcomes at your organization.
And, if you are in the market for an EHR platform, here’s a great resource that can help you choose a vendor.