What does "real-time documentation" involve in a clinical setting?

Real-time documentation involves entering patient information during the visit, which ensures that all data is up-to-date and reflects the patient's current condition and treatment plan. This practice allows healthcare providers to capture information as it occurs, such as observations, treatments, and changes in patient status, leading to more accurate and comprehensive medical records. This immediacy can enhance communication among healthcare staff, facilitate timely decision-making, and support better patient outcomes.

In contrast, documenting after the patient leaves would not capture the nuances of the visit as effectively, since details might be forgotten or misremembered. Using templates is a useful method for streamlining documentation but does not explicitly indicate the timing of the record-keeping. Similarly, transcribing audio recordings introduces potential delays and inaccuracies, as this method depends on capturing already spoken words rather than recording information in real-time.