Junior doctors occupy a unique and sometimes strange position within the hospital. We are doctors. We’re called when people are sick and deteriorating. We prescribe high risk medications. We authorize investigations and treatments that require careful balancing of the risks and benefits to the patient. We certify deaths in the middle of the night. We give bad news. We occupy a position of incredibly high responsibility.
We’re also at the very bottom of the pecking order.
And what always seems to fall to us? Clinical documentation.
Owing to the myriad reasons that we looked at in the previous installment of this article, we often don’t do a great job, and the general standard of documentation is low.
The consequences
In a vicious circle, not only are junior doctors not enabled to create good documentation, but they often suffer the consequences when documentation is poor.
Junior doctors are often the ones who end up wasting time when documentation is incomplete.
When I was an orthopaedic intern, physios would commonly check with me about the weight bearing status of patients. It’s a reasonable question but was usually only necessary because documentation on the admission note or operation report was lacking. The process to finding this out would involve texting the registrar, waiting for a response, going to find the physio, and discussing the outcome. This might not sound like a lot, but when it was happening multiple times a day in addition to other clinical work it became quite burdensome.
It happened so much, in fact, that my colleagues and I had a joke about it. We said that if the physios ever started talking directly to the registrars us juniors would be out of a job!
Frivolity aside, it was a massive waste of time and so easily preventable through appropriate documentation.
Junior doctors rely on clinical documentation when reviewing patients they don’t know.
Ward call. You either love it or you hate it, and a lot of junior doctors don’t love it. When reviewing patients that are completely unknown to you and have high acuity issues, the accuracy of the patient notes is essential. In this scenario, poor clinical documentation can be not just a nightmare that makes the job exponentially more difficult, but a real patient safety risk.
You’re lucky if the notes are even legible. In paper notes, I have reviewed patients and been unable to read a single word of any of the doctors’ entries! Given that I needed the medical notes to determine the patient’s level of risk for life-threatening conditions to be excluded, their medical background, and what issues are already being managed by the team, you can imagine how this paucity of information impacted the quality of care I could provide.
Sometimes the patients on ward call have incredibly complicated medical co-morbidities and are being managed by highly trained subspecialists. If the complex management plan determined by the consultant isn’t well documented, what hope does a junior have of helping these patients?
The Solution
Good news! Given all the frustration that inadequate documentation causes junior doctors, when educated properly they will be enthusiastic about improvement and great drivers of change.
So how can Clinical Documentation Specialists best engage junior doctors within a CDI program?
Link improved documentation to improved funding and, therefore, a less stressed hospital.
This one is simple. Many junior doctors know what it’s like to work in hospitals that are not appropriately reimbursed for the complexity of care provided. If they know that their documentation is what can improve things they will very much be on board!
More specifically, understanding the difference in funding between DRG splits will motivate junior doctors to ensure those additional diagnoses are captured.
Emphasise that quality documentation doesn’t require writing more but can actually result in writing less!
As a time-pressed junior doctor doing a lot of overtime I can’t imagine anything more likely to get my attention! In the junior role it’s easy to feel like a glorified scribe. Time spent working on actual clinical reviews and treatment gets lost in all the paperwork. Juniors knowing that they can get more out of their documentation whilst spending less time on it will kick-start behavioural change.
Relate documentation to the clinical process.
Remind these junior doctors that they are, in fact, just that! Doctors! When reviewing patients, they are already using their clinical framework to think of a working diagnosis, differential diagnoses and life-threatening conditions that need to be ruled out. They just need to write this process down (show your working!), link treatment plans to a working diagnosis, and document that diagnosis as specifically as they can. If they do all that, they won’t go far wrong.
Provide structured advice on completion of the discharge summary.
A lot of junior doctors really dislike doing discharge summaries. They’re boring, repetitive, and take away from time seeing patients clinically.
Now that I have a thorough understanding of coding and DRG assignment, I can see that my discharge summaries were beyond woeful. For elective surgeries I would write “elective admission for…” as the presenting problem and put the name of the procedure as the principal diagnosis! I simply had no idea that was wrong. I’d never been given any teaching on the importance of the principal diagnosis, and nobody ever approached me about my discharge summaries.
This is an area in which a CDS can really shine. Education on how to populate the discharge summary more appropriately is invaluable, and ongoing, real-time feedback cements behavioral change.
Had I known about how my discharge summary would be used to assign codes and a DRG, I’m sure I would have found it a lot more enjoyable!
Educate seniors on the importance of the documentation.
All this cultural change for the junior doctors can only be sustained if the seniors are on board. Explain to registrars and consultants the importance of the documentation the juniors are doing. Let them know that their juniors are significantly improving safety, quality, communication, and financial sustainability. Furthermore, you can educate the seniors as to how they can facilitate excellent documentation by the juniors. Give them strategies such as dictating diagnoses and important points and encouraging the juniors to speak up if they need clarification or explanation.
Recognise improvement.
As a junior doctor I know that recognition for the hard work we do is often minimal. A CDS can quickly become a junior’s favourite person on the ward by recognising and praising improvement. When you’re “onside,” the juniors are likely to go out of their way to engage with you and help you.
A little shameless chocolate related bribery can go a long way too. Remember: within every doctor there’s a three-year-old with a toy stethoscope!
Join the team on ward rounds.
This is possibly the most important thing you can do for your junior doctors.
All doctors are essentially in a decades’ long apprenticeship, and we learn by doing. You can prompt the juniors to document what treatments are for, help them be specific, and support and empower them to ask questions of the seniors.
The take home
With appropriate education and engagement, junior doctors can become powerful allies in your hospital’s clinical documentation improvement journey.
Not only can they actively improve clinical documentation right now, but they are the consultants of tomorrow. By working with junior doctors, you can help create a generation of seniors that value clinical documentation and pass this positive attitude on to their juniors. It may be that one day, each level of the medical hierarchy will value the work of the other levels, changing the face, not only of clinical documentation, but of medical culture itself.
Just don’t forget the chocolate!
Dr Felicity Sinclair-Ford is a medical doctor with a diverse range of educational experiences. As well as studying languages and the humanities at a tertiary level, Felicity has worked as a resident medical officer in hospitals in Queensland, New South Wales and the Northern Territory. Her time in the clinical space prompted her interest in patient safety as it relates to clinical documentation.
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