Proper Practice Documentation « ePractice Manager | Systems for next-level growth

Proper Practice Documentation

By epractice
April 26, 2018

What’s the likelihood you’ll be sued, or have an employee or HR-related complaint issued against your practice? Unfortunately, it may be higher than you think. With related lawsuits increasing at an alarming rate, having correct HR and personnel management procedures is more important than ever.

A vital first step in lowering your risk is proper and diligent documentation within the practice.

What Is Documentation?

Documentation is the written and retained record of employment-related events. It includes all work-related electronic communication, such as text messages and emails. These should be printed and filed (or e-filed), whether from an office computer, or employee and supervisor hand-held devices.

Why Is Proper Documentation So Important?

Accurate documentation keeps the practice covered legally.

Without it, in the event of a suit filed against the practice, an employer would be hard-pressed to provide a record of discussions, timeline of events; and any disciplinary actions.

For example, a written record of exactly what took place on a performance issue (such as an employee’s repeated tardiness or missed staff meetings) will cover an employer when next steps must be taken.

What Should Be Documented?

Always document:

 Job performance reviews
 Questions or situations that arose from poor employee performance
 Positive employee performance
 Disciplinary action taken on an employee, or other personnel actions taken
 Discussion or clarification of policies and procedures with/for an employee
 Responses to employee grievances
 Personnel investigations
 History of all time off
 Salary discussions
 Change in employee status

How to Keep Documentation

Following are guidelines for creating and maintaining proper documentation at your practice. If you strictly adhere to them, you’ll take the first step towards dramatically decreasing HR risk at your practice.

Documentation should be,

1. Created In Real Time –

This is very important. Take notes during meetings, as appropriate, to ensure you don’t forget important details. The more time passes, the fewer the details that will be remembered. Records should be created as close as possible to the time of any incident, meeting, etc.; certainly within 24 hours.

2. Specific and Detailed –

Documentation should be based on a specific incident, and include as much detail as possible. Avoid generalized statements.

Documentation should clearly state:

 What happened
 Where and when it happened
 Who was involved
 What policy or policy section was violated
 If it was necessary to point out consequences of further policy violations, include what was stated.
 Objectives or expectations that stemmed from job reviews, disciplinary actions, assigning production goals, etc. Ideally, you should use measurable terms to accurately gauge performance.
 Follow-through on meeting the stated objectives or expectations

3. Factual –

Leave out opinions, conclusions, your emotional reactions, and labels. If you notice yourself writing subjective comments, stop writing. Such comments won’t be well received, and may upset the employee.

4. Clear and Consistent –

Don’t write up behavior in one employee that you ignore in others employees. Also, make sure the document is written clearly, so it would be understandable to anyone—even a stranger.

5. Signed and Provided to Employee –

Provide space on the document for the employee to add his or her own statement. Have the employee sign and date each document to acknowledge he or she reviewed the contents, and was given a copy. If an employee refuses to sign, make sure to note that on the document.

Finally, keep in mind the reason for any discussion with an employee should be moving toward the goal of improvement of the employee, and his or her performance. You want those under your charge to grow and achieve more. Managers who focus on helping employees become better at their jobs are respected, and gain a great deal of support.

Here at ePractice Manager, we understand that running a practice is stressful, which is why we offer a full suite of onboarding, training, and management resources—to help you focus on what matters most, patient care. Sign up for a free consultation today!

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