The seven criteria for high quality clinical documentation require that all entries in the patient record be legible, complete, clear, consistent, precise, reliable, and timely. The first six are focused on in a review process because they can be corrected after the fact, if necessary. The last criteria, timeliness, is one criterion that cannot be corrected after the fact since once an entry is late, it remains late. Listed below are the seven criteria for high quality clinical documentation.1 The initial definition provided is taken from the Oxford English Dictionary.2 Following the dictionary definition is a description of how the criteria can be applied to patient medical record documentation. Examples of documentation that meet and examples that do meet the criteria are also included after each definition with the exception of legibility and timeliness.
Legible. Clear enough to be read and easily deciphered. The inability to read a record entry is usually due to the fact that the physician’s handwriting is indecipherable. Legibility is addressed as a requirement for clinical documentation by every regulatory body and law that addresses medical record content. The most recent nod to the importance of legibility came when HIPAA gave patients the right to ask for clarification of illegible information in their records. Illegible handwriting is usually the result of a rushed or careless documentation practice. As we evolve towards the electronic medial record (EMR), handwriting becomes less of an issue. However, there are other risks inherent in the rushed or careless use of an EMR that may cause the definition of legibility to be evolved for these purposes.
Complete. Having the maximum content. Thorough. This means that the physician has thoroughly addressed all concerns in the patient record. Completeness also includes the appropriate authentication by the physician or clinician, which generally includes a date and signature. Diagnostic documentation concerns apply to anything from the patient’s initial complaint (did the physician provide a working and final diagnosis?) to ordering of tests (did the physician document the reason for the tests?) to abnormal diagnostic test results (did the physician document the clinical significance of any abnormal diagnostic test?)
Documentation that does not meet criteria for completeness:
Physician orders comprehensive blood chemistries. The tests show low sodium levels, low magnesium levels, and low potassium levels. The physician does not document diagnoses to represent any of these abnormal results, nor does he document that the results are clinically insignificant.
Documentation meets criteria for completeness:
In the example above, the physician documents the following in the patient’s progress notes on the day after the test results were received:
Na 131 Mg 1.3 K+ 3.1; Patient dehydrated. Potassium within normal limits for this patient given CAD and hypertensive medication. The physician should not document a diagnosis if the clinical evidence did not support it. However, if the abnormal test results do not support a diagnosis, then the physician should document, “abnormal test results are clinically insignificant.”
Clear. Unambiguous. Intelligible. Not vague. Vagueness and ambiguity exist when the clinical documentation does not totally describe what is wrong with the patient. This may result in the documentation of symptoms without etiology or possible etiology. For example, if a patient presents with a symptom such as chest pain and the physician provides no other insight in his documentation, it would be considered vague. If there is no clinical evidence for any diagnosis, then the appropriate documentation would be, “chest pain etiology undetermined.”
Documentation that does not meet criteria for clarity:
Patient presents with syncope. The physician orders a CT scan and MRI of the brain, EKG, and blood tests, all of which are within normal limits. The physician’s final diagnosis on discharge is syncope.
Documentation that meets criteria for clarity:
In the above example, the following documentation would meet criteria for clarity, assuming that the appropriate clinical indicators were present:
Syncope, etiology undetermined
Syncope, possible bradycardia
Syncope, probable TIA
Consistent. Not contradictory. Clinical documentation about a patient that contradicts itself from one progress note to the next or among entries from different physicians is a documentation deficiency. The overall rule is that when another physician’s documentation conflicts with the attending physician’s documentation, and the attending is unavailable to state otherwise, the attending physician’s documentation takes precedence. However, if the attending physician has provided documentation that appears to contradict itself, he must clarify and add an addendum to the discharge summary or a final progress note.
Documentation that does not meet criteria for consistency.
Patient is admitted by her primary care physician with vertigo and confusion. The primary care physician documents the patient’s preliminary diagnosis as TIA and asks for a neurology consult. The neurologist examines the patient and documents the diagnosis in his final consultation as cerebrovascular accident (CVA). The attending physician provides no further documentation regarding the patient’s diagnosis. (In this case, the attending physician and the neurologist’s diagnoses are inconsistent).
Documentation that meets criteria for consistency.
The attending physician is asked to re-review the neurologist’s consultation. The attending physician adds a final progress note to the patient’s record that states the final diagnosis is CVA.
Precise. Accurate. Exact. Strictly defined. Detail, if available and clinically appropriate, is an important component of every patient’s medical record. The more detailed the physician’s documentation, the more representative and accurate the clinical documentation in the patient’s record is likely be.
Documentation that does not meet criteria for precision.
Patient is admitted with chest pain, shortness of breath, fever, and cough. Chest X-ray shows aspiration pneumonia. The physician’s final documented diagnosis for the patient is pneumonia.
Documentation that meets criteria for precision.
The physician reviews the chest X-ray and documents the patient’s final diagnosis in the discharge summary as aspiration pneumonia.
Reliable. Trustworthy. Safe. Yielding the same result when repeated. This criteria relates to treatment provided to the patient and whether the physician’s documentation supports the treatment. For example, a physician orders a blood transfusion for a patient who has an upper gastrointestinal bleed and severely low hemoglobin and hematocrit levels. The physician’s diagnosis for the patient is a bleeding gastric ulcer. The physician’s diagnosis of a bleeding gastric ulcer does not appear to be reliable based on the treatment given. Blood transfusion is not an accepted treatment for a gastric ulcer. If the physician documents bleeding gastric ulcer with acute blood loss anemia (if clinically indicated), based on the treatment given, this is a reliable diagnosis.
Documentation that does not meet reliability.
Patient is admitted with shortness of breath and chest pain. The patient is treated with Lasix, oxygen, and Theophylline. The physician’s final documented diagnosis for the patient is acute exacerbation of chronic obstructive pulmonary disease (COPD).
Documentation that does meet reliability.
The patient was given Lasix to treat an acute and chronic CHF. The physician amends the final progress note to reflect the final diagnosis: Acute exacerbation of chronic bronchitis and COPD; acute and chronic CHF. In this case, the patient had bronchitis with the COPD, so the initial documentation did not meet criteria for both reliability and precision.
Timely. At the right time. Timeliness of clinical documentation is essential to the best treatment of the patient. The EMR can help with timeliness, but the clinician’s input is still necessary. In addition to daily progress note entries and timely discharge summaries, physicians also need to be timely with diagnoses that are present on admission. Hospitals need to report when a diagnosis was present on admission as evidence that the condition did not develop in the hospital. Present on admission documentation impacts research, reimbursement, quality indicators, and planning.
The table below is a summary of criteria for high quality clinical documentation along with representative examples.
Documentation criteria | Example/description |
Legibility | Required under all government and regulatory agencies |
Completeness | Abnormal test results without documentation for clinical significance (JCAHO requirement) |
Clarity | Vague or ambiguous documentation, especially in the case of a symptom principal diagnosis (chest pain vs. GERD or syncope vs. dehydration) |
Consistency | Disagreement between two or more treating physicians without obvious resolution of the conflicting documentation upon discharge |
Precision | Non-specific diagnosis documented, more specific diagnosis appears to be supported (anemia vs. acute or chronic blood loss anemia) |
Reliability | Treatment provided without documentation of condition being treated (Lasix, no CHF documented; KCL administered, no hypokalemia documented) |
1Russo, R., & Fitzgerald, S. (2008), Physician Clinical Documentation: Implications for Healthcare Quality and Cost, Academy of Management Annual Meeting, Anaheim, CA; Russo, R., Fitzgerald, S., Yam, M., and Medio. F. (2007). Improving self-efficacy and organizational performance: Identifying the differences that may exist from educational interventions crafted to utilize two versus all four self-efficacy constructs, Touro University International Dissertation.
2 Oxford English Dictionary (2005). Oxford, England: Oxford University Press
