Our New Healthcare Heroes: The Next Generation of Clinical Documenters

It’s a frenetic time in Australian hospitals. After two years of COVID-19 suppression strategies, our borders, our country, and our lives, have opened up again. However, these newfound freedoms have resulted in the deadly Omicron wave. Our hospitals have been working tirelessly to treat those with severe COVID, and we couldn’t be more grateful to them.

But there’s something else that has happened over the last few weeks. Something with little fanfare, that you’re unlikely to read about in the newspapers. Something that is essential to the future of healthcare, and our hospitals’ ability to provide care during this, and any future, pandemics.

The commencement of graduate clinicians.

After years of hard work and study, sacrifice, and dedication, at the end of last year thousands of nursing, medical, and allied health students walked across a stage, shook hands, and received a certificate.

And for these fresh faces, the theory is about to get very, very practical.

Each year, thousands of clinicians start working in the hospital environment for the very first time. Having only done placements before, they now need to step up, shoulder a massive responsibility, and care for their communities.

You might be wondering why we’re talking about this on a Clinical Documentation Improvement blog.

The answer is the poorly documented elephantiasis in the room.

I can certainly speak for myself, and many of my colleagues, when I say that clinical documentation is taught poorly, if at all, during medical school. Talking to nursing and allied health friends, the situation in their degrees isn’t any better.

For medical students, the most common way to learn documentation is having a paper chart thrown at you during a ward round. Someone says, “write the notes and I’ll counter sign it”. You do your best to hold this weighty tome, follow the consult, and document what you think is important.

If you’re lucky, your hospital has a digital record, and, instead of having a chart thrown at you, you have a workstation on wheels propelled forcefully in your direction, like a trolley pushed through an empty carpark towards the trolley bays.

So if we step back and think about it, we have thousands of new clinicians starting in our hospitals, who all have almost no knowledge of the importance of documentation for patient safety, hospital funding, and data integrity. If no-one intervenes, these young practitioners will absorb the documentation culture of the hospital. Who knows how many thousands of dollars will be lost as a result? How much data skewed? How many adverse events caused?

We’ve all heard the adage “start as you mean to continue”. Use this fantastic opportunity to have these new clinicians document well from the get-go. This time is a fantastic opportunity to educate interns, graduate nurses, and new allied health practitioners on the importance of their clinical documentation.

For now, just start with the basics. Give them an overview of how casemix funding works. Interns will be a lot keener to do their discharge summaries if they know they’re essentially funding the hospital! Ensure they understand the importance of an accurate Principal Diagnosis, and that they know the implications of the order of diagnoses on the discharge summary.

Let them know who the clinical coders are! That there is a whole team of fantastic people who will read every single word they write (scary!) and assign diagnosis and procedure codes.

Explain to them that, for diagnoses to be coded, they need to be specifically documented and linked to the treatment, diagnostic procedure, or increased clinical care.

Make sure they know what your role is, how it works, and why you’ll be approaching them to have clinical discussions.

This essential information on clinical documentation will set them up for success.

But we know that a single education session at the beginning of the year simply can’t effect behavioural change. Remember that these new clinicians are being bombarded with new information in their first few weeks.

Follow up with regular education, both formal and informal, throughout the year. Let them know that you are there for them to guide them and answer any questions they may have. Better yet, accompany them on ward rounds and empower them to ask their seniors for diagnoses and specificity.

To take a slightly different approach, also be there for them as a person.

For all new clinicians, the first year of working clinically is a difficult one. Seeing a friendly face could be the difference between someone finishing their intern year and achieving general registration, or not.

I found my intern year incredibly tough. A steep learning curve, the exhaustion of shift work, and a sometimes crushing sense of responsibility made it a year I’ll never forget. I can’t even imagine what it’s like for those entering the workforce during Australia’s biggest COVID wave.

So for these Healthcare Heroes, the newest on the block, let’s support them, guide them, but, importantly, make them excellent, excellent documenters.

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