Being clean, clear, and concise may not be written rules for clinical documentation, but they can help you and your patients immensely. The language you choose, whether subconscious or purposeful, can display your level of care and the necessity of the aid you provide. The most effective way to prove your point is a compelling narrative, something that will engage your reader at any level from patient to health insurance provider. If you remember these 3 points, your documents can be easily read and more effectively used.
The first step is making sure your documents are free from spelling mistakes and grammatical errors. Nothing can hurt your cause like an “are” that should be “our,” a “here” that should be “hear.” Whether you do this step as you write or after the fact (we recommend both), it’s integral to effective communication and keeps your reader from being pulled out of the story you are trying to tell.
Now, you may have distinguished “their” from “there” from “they’re,” but if you’re using them to say things like “they’re antidisestablishmentarians,” then perhaps you might want to a) ask yourself if you’re actually writing in regards to a patient and b) break things down a little for digestibility. While there is a level of aptitude required in the field, over-the-top language weighs down your writing and, similarly to bad grammar, will disrupt the flow of your thoughts.
You’ve paid attention to the little details and made sure to keep your documents readable. That’s great! All you must do now is to be sure you’ve been brief and to the point. While the other two may guarantee reader engagement, you want to take them down the narrative path that’s most relevant and to the point. You may have written wonderfully crafted sentences that are easy to read, but make sure everything comes back to the idea your trying to get across.
So that’s it. Simple enough, clean, clear, and concise. The key to good documentation and a great narrative.