Redesigning a Documentation Template in Five Steps
When documentation keeps falling short, the usual response is another round of training. Training has its place, but it rarely holds when the form itself works against the writer. If a template asks for twenty fields in an order that doesn’t match the work, people will fill in what is required, skip what is optional, and leave the important detail somewhere nobody looks.
The form decides what gets written. That is the reason to fix the template first and retrain second. The five steps below are a practical way to do it without turning the project into a system overhaul.
Step 1: Pick one workflow
Choose a single high-volume process where incomplete notes cause visible rework: a referral, an intake, a care coordination contact, a prior authorization request. Resist the urge to redesign every template at once. One workflow gives the team something it can finish, test, and learn from in a few weeks.
Good candidates share three traits:
- The note is handed to someone else to act on.
- Staff often have to call or message the writer to ask what they meant.
- Delays in that workflow are easy to see, so improvement will be easy to see too.
Step 2: List what the next reader needs
Before touching the form, identify who reads this note next and what they must know to take their step. Ask them directly. A scheduler, a supervisor, a reviewer at a health plan, and a community partner each need something different.
For each reader, write down:
- The decision or action they take after reading.
- The facts they need to take it, and where those facts usually come from.
- What they currently have to chase down because it isn’t in the note.
That last list is the most useful thing the project will produce. It is a direct map of the gaps the template creates. A well-organized prior authorization submission, for example, is simply easier to approve, and the reviewer’s needs are usually knowable in advance.
Step 3: Cut and reorder fields
Lay the current template next to the reader’s list. Every field should earn its place by serving a decision someone makes. For each one, ask:
- Does anyone use this? If no reader acts on it, remove it or make it optional.
- Does it invite inconsistent answers? Free text where a short pick list would do, or a pick list missing the most common answer, both produce noise.
- Is it in the right order? The form should follow the sequence of the work, so the writer fills it in as things happen.
- Is observed information separate from assumed information? A field for what was confirmed, and where it came from, prevents a guess from traveling as fact.
Keep some room for narrative. Structured fields help records move between systems and make reporting easier. A short free-text space still matters for the context a pick list can’t capture.
Step 4: Add an owner field
Most templates record what was done. Fewer record who owns what happens next. Add a required field for the next action, the person or role responsible, and the date it is due.
This one change does a lot of work. The next reader sees immediately whether they are expected to act. Supervisors can see open items without reading every note. And when the original writer is out, the task doesn’t disappear with them, because what one person knew is now written where the team can find it.
Step 5: Spot-audit, then adjust
Once the new template is in use, pull a small sample of recent notes on a regular schedule, perhaps ten every two weeks for the first couple of months. Check them against the reader’s list from Step 2:
- Could the next person act without asking a follow-up question?
- Is the owner field filled in, with a real name or role and a date?
- Are any fields consistently skipped or answered in different ways?
Share the results as information about the template, not as a score for individual staff. If a field is skipped by most people, the problem is usually the field. Adjust it, check again, and only then decide whether any targeted training is still needed.
Where training fits
Training works better after the redesign, because it can be short and specific. Instead of a general session on writing good notes, staff can see two or three strong examples from the new template and hear from the people who read their notes about what helps. That feedback, tied to a real workflow, tends to stick in a way that general reminders don’t.
The best measure of a template is not how complete the notes look. It is how rarely the next person has to stop and ask.
About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.
