Physicians’ clinical documentation and patient’s healthcare management: The need for pragmatic approach

Abstract

Background/Objective Clinical documentation is an important legal and professional requirement for health professionals and goes a long way to determine the value of care a patient receives. Methods/Design: This study reviewed and discussed issues relating to physicians’ clinical documentation and reported on opinion assessment of physicians with regards to clinical documentation. Result: It was found that clinical documentation serves as a basis for organizing the patients care plan and for continuity of care. Physicians, as well as other healthcare providers acknowledge the importance of effective clinical documentation. However, inadequacies persist in existing clinical documentation practice especially in paper-based systems. Conclusion: The study recommends that hospitals need to develop written policies and guidelines on clinical documentation for physicians. In addition, there should be regular clinical documentation training programme for physicians and other care givers in order to reduce errors during documentation.