Clinical documentation

Why it matters

What is not written down cannot be handed over, audited or counted. Documentation carries clinical reasoning from one clinician to the next and is the source of every indicator a hospital reports. It also takes time: a study of primary care facilities in five low and lower middle income countries documented the workload health workers carry in recording and reporting data [1].

Key points

• Structured fields, such as vitals, diagnoses and coded problems, can be reused for decision support and reporting.
• Free text captures nuance but is harder to analyse; good systems combine both.
• Coding diagnoses with ICD 10 or ICD 11 makes documentation comparable across facilities and countries [2].
• ISO/TR 20514 describes the EHR as a record in computer processable form, accessible to multiple authorised users [3].

In Moana

In MOANA Desktop, clinicians record the chief complaint, symptoms, notes and vitals in a guided visit, and every entry is attributed to the person who made it.

Sources

1. The burden of recording and reporting health data in primary health care facilities in five low and lower middle income countries, BMC Health Services Research (Siyam and colleagues), 2021
2. WHO releases new International Classification of Diseases (ICD 11), World Health Organization, 2018
3. Health informatics: electronic health record definition, scope and context (ISO/TR 20514), International Organization for Standardization, listed by the Australian Digital Health Agency, 2005