So far in this series on documentation, we have looked at ways to capture information that should be documented and also when to document. This week we look at how to write professional client progress notes or documentation.

Client Progress Notes are Legal Documents

When writing progress notes, keep in mind that they are legal documents which can be brought before a court of law, so here are a few tips to ensure that your notes are acceptable and defensible.
Client file or progress notes can be used in a court of law.

1. Always check that you are writing in the relevant person’s notes

This means making sure you have the correct ‘identifiers’ on the page before you start. Identifiers are a person’s name and their date of birth. Some organisations also use a code for each individual – this helps when you have two Mary Browns with similar dates of birth. Never write notes on a blank sheet, even if the notes are contained within the person’s file; always ensure identifiers are noted on each individual page.

2. Use a blue or black pen

Blue and black pens are the colours of preference for legal documents as they photocopy well and are easier to read. Avoid the use of red or other coloured pens as these are harder to read and do not photocopy well; although pretty, they are not considered acceptable colours for legal documents. Your written comments also need to be indelible – this means they cannot be erased – which means you cannot use either pencils or erasable ink pens.

3. Write legibly

Your notes need to be clear and easy to read and decipher. This is not the time to see how many words you can cram onto a single line; take the time to write neatly and in a size that is easy to read. Printed words rather than cursive lettering is fine and, although it can look like you are shouting, it is okay to print in capital letters if this ensures your notes are legible.

4. Note the date of your entry

If you are writing about something retrospectively, you can include the date and time of the event within the body of the note.

5. Sign your entry

This may be a full signature or your initials – it will depend on your organisation’s policy. Make sure you sign directly after your last word to minimise the possibility of anyone adding additional notes after yours.

e.g. …took Mrs Smith to clinic to pick up her medications.—B. Jones

6. Avoid blank space between entries

It might appear crowded, however you should never leave blank lines or space between entries. If you have a blank line that you don’t want to write on, draw a line through it, as this will avoid the possibility of someone inserting additional notes in the space. Similarly, if you have accidentally started a new page and discover that the previous page still had white space, draw a ‘Z’ shaped line through the blank lines.

7. Make it clear if notes span more than one page

If you move from one page to another you need to highlight that your note continues. Add ‘Note continues overleaf’ at the end of the page. At the beginning of the next page add the words ‘Continued from previous page’ before resuming your entry. This practice ensures that anyone reading the entry understands that the information is spread over the two pages and won’t miss any important details.

8. Errors happen

If you make a mistake, simply place a line through the word. Do not use white out or try to black out the entry. If you have made a note in the wrong person’s progress notes (see ‘identifiers’ in Tip #1), you will need to rule a line through the entry and make a note that the information was written in the wrong client’s file by using the words ‘notes entered against incorrect client’. Remember to sign and date this!

9. Use the correct words

Do not try to write complex words unless you are sure of their spelling and meaning. If you use a word incorrectly and your notes are subpoenaed due to an incident, it may appear that you or the organisation have taken an incorrect path of care. For example, the words anuresis and enuresis look and sound similar but they have opposite meanings:
anuresis – unable to urinate or lack of urine
enuresis – bedwetting

Even simple words can trip people up such as the words:
excess – too much of something
access – to gain entry

What about:
dysphagia – having difficulty in swallowing
dysphasia – the loss or difficulty in using or understanding speech

Remember that even many simple words that sound the same are spelt differently and have different meanings; plain and simple language is the best coarse course of action. Access to a dictionary (paper or online) can be one of your best friends.

10. Beware the acronym and abbreviation

An acronym is a word or name created out of the initial letters of words in a phrase, e.g. Commonwealth Home Support Programme = CHSP or ADL’s = Activities of Daily Living.

An abbreviation is a shorthand version of a word or phrase that may be used repeatedly, e.g. Mr = Mister (originally Master) or Mrs = Missus (or originally Mistress). 

It is always best to use the full word/s where possible rather than use an abbreviation or acronym, as this is less likely to lead to misinterpretation. However, if you do use a shortened version of a word or phrase, ensure that it is either a standard across the industry, with no chance of misinterpretation, or is one approved by your organisation.

Many large health organisations have an approved list of abbreviations, with these being the only ones allowed when writing progress notes. Check with your supervisor or manager if you are unsure.

11. Keep your entry professional

Lastly, ensure that your entry does not contain assumptions, judgemental language or red flag terminology.

Just because a person looks glum does not mean they are sad. Just because someone is staggering does not mean they are drunk. Keep to known observations. State only what you heard, saw, smelt or felt.

Joe felt hot to the touch – not Joe has a fever (maybe he has been sitting out in the sun all day);

Billy was observed to be unsteady on his feet – not Billy was drunk because he was staggering around (Billy may be exhibiting signs of a neuro degenerative condition such as Machado Joseph Disease – MJD);

Sarah smelt strongly of urine – not Sarah was incontinent (Sarah may have been sleeping on a mattress that was urinated on by someone else).

When you state that Trixie was being offensive or obstructive, you are making a judgement call on her behaviour – Trixie’s behaviour might offend you, however her intent might be otherwise. If you merely state the actions that Trixie has taken and your response to that, you are maintaining professional neutrality.

Red flag terms describe words or phrases that can lead to sensationalism. These could be describing a person as being the ‘victim’ of domestic abuse or there is an ‘epidemic’ of scabies within the household.

Just remember, stick to the facts and only the facts.

Of course, for organisations using electronic progress notes, some of these points will be obsolete as the system will generate a time and date stamp and your notes will be legible. However, you still need to take note of the content. Take a minute to re-read your entry before you hit save, checking the wording used and always log out after making an entry, otherwise you are allowing another person to access your electronic signature.

This post is Part 3 of our four-part series on client documentation – check out our other posts now:

Part 1: 4 Ways to Make Client Documentation Easier
Part 2: Progress Notes – what should you document?
Part 4: Correct Storage of Client Documentation – For Your Eyes Only!

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