Documentation in Health Systems: What’s Important and What’s Not

Updated on August 28, 2020

By Kevin Torf

With hospitals and health systems at the forefront of the current global pandemic, many are facing challenges managing IT infrastructure due to the sudden massive demand for remote technology. A key component of successfully managing these types of transitions and changes in workflow processes is documentation. Documentation is a crucial tool for health systems, but it only works if everyone responsible knows why it’s happening and why it’s important.

Decisions regarding what will be documented throughout the course of an IT project and how these records will effectively be maintained are vital for overall success. It’s also important for hospitals and health systems to differentiate between project-driven and operational documentation, as this will further help identify ‘the why’ behind what you’re documenting and how it serves the needs of the current project and future operations. One key to success – making upfront decisions regarding what will be documented throughout a project and how those records will be effectively maintained. Not only does this streamline project needs, a strong documentation strategy can greatly influence the effectiveness of healthcare organizations and the ongoing management of day-to-day operations. 

IT project managers in healthcare need to keep in mind that there’s no one-size-fits-all approach to documentation – it will be dictated by, and must be responsive to, the requirements of the project and the capacity of team members to update and maintain records. The five tips below can help organizations perfect the documentation process and ensure that the records kept will serve their purpose: 

Pinpoint ‘your why’ 

Before starting a project, it’s best to think about what actually needs to be documented, and why. It’s crucial for all team members to know the reasoning behind each documentation decision, as the mistake of tracking too much information is just as common as the mistake of tracking too little. Consider what information will be needed for reports throughout the lifecycle of a project. What data needs to be consistently tracked so that project records will be accurate and up to date processes, roles and responsibilities, timelines, budget, configurations, inventory, and required resources. Keep in mind that some project records might contain useful information that could form the basis of, or be added to existing, operational documents. The most important thing here is having a concrete answer for why each piece of information is being documented.  

A ‘why’ doesn’t work without a ‘way’ 

Incomplete records are useless and will cause frustration and mistakes. It’s best to carefully assess the documenting capabilities of your team and then, assign individuals to realistic documenting tasks, with clear instructions on how to keep records updated throughout the course of the project. Some team members will say they don’t enjoy the administrative side of projects and feel that documentation takes up too much time or isn’t as important as other aspects of the project, so show them easy ways it can be done and why it is needed in the long run. You can help your team learn how to write in a clear and succinct manner to help alleviate any feelings of burden or overwhelm toward documentation duties. With so many moving parts within documentation, it’s important team members feel confident and comfortable with their given tasks. 

Build documentation into the flow of the project

Overall, documentation systems shouldn’t be a phase of a project that happens after all tasks have been completed, it should be considered as part of what’s required to finish each task. Integrate documentation into your team’s workflow to ensure it’s happening constantly and consistently. It’s rare that a project goes completely as planned, so make sure your documentation processes are updated if any changes in the project’s scope, strategy or deliverables take place. It will be less burdensome documenting as you complete tasks, versus waiting until the end of a project once it has all piled up.

Differentiate between project-driven and operational documents, and keep the latter active

While project-driven documents may just be for record keeping after a project is complete, some documents will remain active as part of day-to-day operations for hospitals and health systems. Continue to keep these relevant and updated by evaluating how operational needs differ from the initial project needs. Operational documents most likely will need to be pared down – they should contain only the minimum amount of information required to be useful and effective. 

Evaluate frequently

Reassess your documentation routines and processes monthly, quarterly and when there are any changes to your systems or business environment. As always, question your documentation decisions and have answers for the ‘who,’ what,’ ‘when,’ ‘where,’ and most importantly, ‘why’ – while not forgetting the ‘way’.  

Now more than ever it’s important that IT project managers can create and manage successful documentation strategies for health systems. An organized, efficient documentation strategy can be the deciding factor between a project’s success or failure, and the need to maintain continued documentation can greatly influence the effectiveness and ongoing management of day-to-day operations. 

About Kevin Torf

Kevin Torf, co-founder and managing partner of T2 Tech Group, has been a renowned innovator and thought leader in the technology industry for over 35 years, specializing in large-scale IT strategic planning, project design and implementation. Kevin brings decades of experience in complex application deployment, IT architecture, electrical engineering and data center construction, infrastructure and consolidation, particularly within the healthcare space.

The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.