How do you document interdisciplinary team meetings with physicians?

2 Use a standardized format and language

One of the challenges of documenting IDTs is that different disciplines may use different formats and languages to record their findings, recommendations, and interventions. To avoid confusion and inconsistency, it is advisable to use a standardized format and language for your documentation. For example, you can use the SOAP (Subjective, Objective, Assessment, Plan) format to structure your notes, and use common medical abbreviations and acronyms that are familiar to all disciplines. You can also use a template or a checklist to ensure that you cover all the essential elements of the IDT.

3 Highlight the interdisciplinary collaboration and communication

Another important aspect of documenting IDTs is to highlight the interdisciplinary collaboration and communication that occurred during the meeting. This means that you should not only document your own input, but also acknowledge and integrate the input of other disciplines. For example, you can document how you consulted with the physician about the patient's diagnosis, how you coordinated with the therapist about the patient's treatment plan, or how you communicated with the social worker about the patient's discharge needs. By doing so, you can demonstrate the value and effectiveness of the IDT and the patient-centered care.

4 Be clear, concise, and accurate

Finally, when documenting IDTs, you should always aim to be clear, concise, and accurate. This means that you should use simple and precise language, avoid jargon and slang, and check your spelling and grammar. You should also document the facts and evidence, avoid opinions and assumptions, and cite your sources and references. You should also document the date, time, duration, location, and attendance of the meeting, as well as any follow-up actions or referrals. By being clear, concise, and accurate, you can ensure that your documentation is reliable, credible, and compliant.

Documenting IDTs with physicians can be a complex and demanding task, but it is also a vital part of providing quality care to your patients. By following these tips, you can improve your clinical documentation skills and enhance your interdisciplinary collaboration and communication.