March 18, 2015

young woman showing how to document

Good Documentation Habits

We’ve discussed the importance of good documentation habits in your dental or medical practice in a previous ESS trainer, but it’s such an important topic that it’s worth revisiting.

You’re probably well aware that formal Corrective Actions must always be documented properly, but our CEDR Solution Center experts are frequently asked about how to document for informal notes created before or outside of the Corrective Coaching process.

These less formal notes often take the form of first and second warnings about issues that may or may not ever escalate to the point where a sit-down coaching session or Corrective Action is needed. However, even your most casual notes can be useful forms of documentation if done properly, and will create a fuller picture of your management efforts.

Note: The problem areas and pointers we’ll discuss below apply to all your written recordkeeping, formal or informal.

Above all, you’ll want to avoid the following:

  • Missing information. If needed later for evidence, many notes fail on the basis of being unsigned, undated, or illegible.
  • Documentation after the fact. Any notes you create need to be timely — the longer you take, the less genuine your documentation will appear. Creating a note days or weeks later can render it unusable or bring it into question. And keep in mind that backdating is always ill advised, because it is almost always found out. Once that occurs, all of your documentation is called into question.
  • Vague wording. Managers often want to generalize in their notes, because being specific can feel like you are attacking. This might help the employee make a case later, but it won’t ever help you.
  • Reaching conclusions you can’t support. It may seem obvious to you what is going on or why an employee is behaving in a certain way, but you need to support any conclusions with what you actually observed.

Instead, be specific. Good notes are always:

  • Legible
  • Signed
  • Dated (should be as soon after the incident as possible)
  • Specific
  • Supported

Make sure to document not only the problem and what was observed, but also what you said to the employee regarding the issue, impact, and the resolution you need them to make. This doesn’t mean that informal notes need to be pages long — just include all of these basics.

Let’s take a look at a few examples of bad vs. good documentation.

Example 1:

Bad (vague) documentation — “Discussed with Becky that she needs to be on time in the mornings.”

Good documentation — “Informed Becky this morning, when she arrived late for work late, that this was her 2nd tardiness in less than 4 weeks. Explained the policy regarding being on time to her again, and reminded that she is still in our getting acquainted period. She indicated she was sorry, and when asked by me if she could be here on time every day, she answered yes.”

Example 2:

Bad (vague) — “Becky seems to be having trouble with the phone scripts.”

Good — “As of today, Becky is unable to pass the phone script test after 4 weeks of training. She’s been given 2 opportunities to pass by our outside consultant’s team.”

Example 3:

Bad (no support) — “Becky returned to work after having been drinking and was drunk.”

Good — “Becky returned to work and seemed to be impaired. Observed her stumble and smelled alcohol on her breath. When I asked her if she was OK her speech was slurred. I asked her if she had been drinking and she denied it. When I asked her to explain the smell of alcohol, she told me she had one sip of her friend’s margarita at lunch. I told her to clock out and sent her home. I asked her to see me in the morning before she clocks in to return to work.”

Final thoughts: When the documentation hits the fan…

Regardless of what the employee issue is or how far it goes, remember this: all of your notes must be legible, dated, and signed in order to provide the best possible evidence, should it ever be required.

And when in doubt about a particular employee situation, or how to document a particularly difficult situation, consult with an expert. If termination starts to seem likely, you’ll need to be sure that your documentation, along with your practice’s employee policies, are fully up to date and in line with all applicable employment laws. Call 866-414-6056 if you have any questions or for a quick, FREE evaluation of your current employee handbook to ensure your policies are updated and legal, and will help support (not hinder) your management practices.

Friendly Disclaimer: This information is general in nature, and is not intended to replace good counsel about a specific issue with either your attorney or your favorite HR expert.

Friendly Disclaimer: This information is general in nature and is not intended to provide legal advice or replace individual guidance about a specific issue with an attorney or HR expert. The information on this page is general human resources guidance that is believed to be current as of the date of publication. Note that CEDR is not a law firm, and as the law is always changing, you should consult with a qualified attorney or HR expert who is familiar with all of the facts of your situation before making a decision about any human resources or employment law matter.