Alcoa-C+ for Beginners
What it is and why it matters.
Clinical Documentation best practices
alcoa-C+ Key Principles:
Attributable: Trace every entry to a person, date or event.
Legible: Ensure all records are easy to read and signatures are clear.
Contemporaneous: Document events as they occur.
Original: Use the first record or certified copy.
Accurate: Provide precise consistent information.
Complete: Cover who, what, when, where, why or how.
handling errors
In-case a mistake is made or an event occurs, document what happened, why and how to prevent it.
Implement changes and inform the staff.
Report protocol deviations to the IRB.
Best practices
Write legibly in Blue or Black Ink.
Record facts accurately and promptly.
Avoid shorthand, vague terms, and documenting care before it’s provided.
Proper documentation is essential for data integrity and compliance in clinical research, and will save you time and tears on audits, if ever.
compliance style guide
Instead of writing:
“Patient upset about long wait and left.”
Write this instead:
“Subject left early due to personal commitments after understanding the protocol.”
Instead of writing:
“Blood draws not done because Husband objected.”
Write this instead:
”Blood draw was unsuccessful, and subject’s spouse declined further attempts.”
When writing a protocol, note-to-file, report, irb amendment, etc., keep in mind…
The Flesch-Kincaid Grade Level Score across all study documents.
Don’t draw out and make the writing dense. Keep it simple.
Know your audience, and use appropriate language for your audience, in the correct cultural context, without overstating benefits, or using scientifically dense jargon, while keeping it clear and understandable.
Exemplify institutional and clinical values through your writing. While complex concepts may not be easy to digest, always try to do so. You’re here to help clinicians and scientists exact the best outcomes with the least harm.
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