Clinical documentation is the best way to communicate in any healthcare setting. In a growing demand for primary care services, effective interprofessional communication is crucial for positive patient outcomes. My clinical rotation taught me that documentation was often overlooked. Many practitioners perform procedures without documenting what was done.
It is clear that physicians and nurses need to have an in-depth understanding of the communication needs in order for them to be effective in formulating composite healthcare decisions. This will allow them to play a vital role in the provision of high-quality, safe care. A second benefit is that healthcare workers can collaborate to create a better environment for communication. In this respect, interprofessional communication is crucial in the bridging of communication gaps. The finding that good communication influences the safety, quality, and enjoyment of care is consistent with earlier research that link these crucial performance areas to patient-centeredness. In my clinical rotations I advocated clinical documentation excellence and distributed evidence-based materials demonstrating its impact on patient outcomes. Some practitioners viewed documentation as something they did every day. However, I organized a series education workshops to change this perception. The result: nurses reported seeing a significant shift in how they practice nursing.
Although I tried to incite change within the clinic areas concerning documentation, it was impossible to see that there was sufficient staffing. Although it can be challenging to take care of multiple patients in a single shift, you still need to complete history and documentation. For me, it is important to only care for the patients that I have the ability to and to delegate other shift staff to take over.