QA and professional development around documentation

It can be super tedious to have our typos pointed out, or to have quality assurance get back to us with clarification requests and follow-up questions about our documentation as clinicians.

But I had another experience this morning with QA that reminds me that these are actually opportunities for us to improve our clinical practice and our documentation. I had completed a report, then had responded to questions in an addendum to that report, and then asked to respond to a clarification around that addendum. *sigh*

But those clarification questions highlighted for me some referral question details that I had actually missed the first (and the second) time around. And maybe next time I’ll be more alert to those details?

We rarely get the opportunity to appreciate how the end-users of our notes and reports (504 committees, attorneys, physicians, parents) experience our documentation. When we do get a chance to hear that feedback (“David your response to question number two doesn’t make any sense,” or “David, what does neurovegetative mean?” or occasionally “David your report was easy to read and way helpful”) it is actually pure gold in terms of our own professional development.

I was once deposed, with two attorneys and a stenographer. People had driven in from 30 to 60 minutes for this meeting. After lots of formalities and redundancies, there was a final question which clarified things for both attorneys. I said “so if I had just put that in my report we wouldn’t have needed this meeting?” And they were like “yep.” And from the time of that meeting forward, I have tweaked the language in my documentation with those end readers in mind.

Having that experience again today, I decided to emphasize the professional development potential of feedback, and thanked the referral source for their persistent follow-up questions. If my goal is to get 1% better every day, that persistence has helped me on my way.


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