Documentation Principles
Clinical documentation is not administrative work. It is part of clinical care. Good notes help teams make safer decisions, maintain continuity across visits and providers, avoid duplicate tests & support audits ISO 18308 and medicolegal reviews.
This page information supports: ISO 18308 DKICT-V5 ISO 13606-1
Make every note accurate, complete and useful for the next clinician, clinical reporting, and continuity of care.
The Five Principles
Principles in Detail
Accuracy
Document what you actually observe and do:
- Use objective findings and measurable data where possible.
- Separate patient-reported information from clinical findings.
- Verify critical details before saving (medication, allergies, dates, doses).
- Document uncertainty when you are not sure.
- Correct errors using approved CCMS procedures.
✅ Good: "BP 160/95 mmHg. Patient states they missed amlodipine for 3 days."
⚠️ Avoid: "Patient non-compliant."
Completeness
Document all clinically relevant information:
- Complete all mandatory fields in the template.
- Include key negatives that you assessed (for safety and differential diagnosis).
- Document your clinical reasoning, not only the conclusion.
- Record education and counselling provided.
- State clear follow-up and safety-net advice.
- If information is unavailable, document why.
✅ Good: "Chest: clear equal air entry bilaterally, no wheeze/crackles. CVS: normal S1/S2, no murmur."
⚠️ Avoid: "Chest and CVS normal."
Timeliness
Document during or immediately after the encounter:
- Real-time documentation is preferred.
- Complete notes before ending the shift.
- Late entries should be clearly labelled and justified.
- Avoid documenting from memory days later.
Memory fades quickly. Small omissions (timing, dose, red flags assessed) are often what make notes unsafe.
Clarity
Write so another clinician can understand and act:
- Use clear, unambiguous language and standard medical terminology.
- Avoid ambiguous abbreviations.
- Structure information logically (History → Exam → Assessment → Plan).
- Make your reasoning explicit.
✅ Good: "Sudden-onset severe headache at 2pm with photophobia and neck stiffness. Exam: positive meningismus. Referred to ED urgently for suspected meningitis."
⚠️ Avoid: "HA today, sent to hosp.
Relevance
Focus on what changes decisions:
- Document details that affect diagnosis, management, or risk.
- Include context that supports your reasoning.
- Avoid irrelevant personal details.
- Aim for "useful and complete", not "long".
✅ Good: "Works as construction labourer. Back pain for 2 weeks, limiting ability to lift at work."
What Quality Documentation Looks Like: H-E-A-P (ISO 13606-1)
Use this structure to self-check any note:
Red Flags: What to Avoid
1. Copy-paste without verification
Carries forward outdated or incorrect information. Copy only as a starting point, then update it to reflect today's encounter.
2. Vague entries
Other clinicians cannot understand your reasoning. Include measurements, timing, severity, location, and key negatives.
3. Missing assessment or plan
Data without interpretation does not guide care. Always state your assessment and plan explicitly.
4. Contradictions across sections
Undermines credibility and causes patient safety issues. Reconcile discrepancies and correct properly.
5. Missing SNOMED coding
In KKM, uncoded diagnoses are invisible to MOH clinical reten. A patient with free-text 'DM' will not appear in your clinic's NCD registry or HbA1c monitoring reports. Always attach a SNOMED code to the consultation diagnosis
Professional and Legal Context
Clinical documentation is a professional responsibility and a legal record in Malaysia DKICT-V5. Document primarily for patient care. Medicolegal protection follows from good care and good records.
A useful rule: If it is not documented, it may be treated as not done.
Contributor
Dr Fuad Jaafar
Facilitator, CCMS • KK Bandar Maharani