How to Complete Patient Documentation on Time Here are some expert strategies to complete clinical charting in time and ensure accurate, up-to-date, and complete information in the EHR.
Medical records comprise different types of documentation including history of patient, clinical findings, diagnostic test results, preoperative care, operation notes and discharge summaries. Completing patient documentation in a timely and accurate way is a major task for busy healthcare providers. Today, many providers rely on a medical transcription Service Company for medical record creation and maintenance and to complete charting in time. According to researchers, the length of time that clinicians use EHRs to support the care delivery process is a concern due to its possible impact on patient care and the high expenses associated with this time, particularly for medical specialists. EHRs are designed to improve the charting process during the consult, though it impacts the physician’s time with the patient. To ensure accuracy of documentation, enhance care delivery, and prevent provider stress and burnout, systems and processes must be optimized. Here are seven tips to complete patient documentation
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on time, including recommendations provided by American Academy of Family Physicians (AAFP): 1. Perform EHR charting in the exam room:
The key benefit of completing
documentation in the exam room is accuracy. Dictate aloud when reviewing the patient’s health history or treatment plan and medication reconciliation. Dictating aloud will help engage the patient, improve understanding, and ensure accuracy. 2. Get assistance for documentation: Involving your care team in the documentation process can save time. Have a nurse or medical assistant document patient outcomes, review medications, and verify or record allergies. You can sign the note after quickly assessing this information for accuracy. 3. Document only what is medically necessary: The AAFP notes that knowing the latest Evaluation and Management (E/M) guidelines is essential to ensure quick and accurate documentation. New guidelines and coding requirements were introduced in January 2021 for outpatient E/M CPT 99202-99215 office visits. History and/or physical examination are no longer elements for code selection. Physicians can opt to base their documentation on medical decision making (MDM) OR the total time spent on the day of the encounter. 4. Use the EHR’s time-saving features: EHR systems come with many time-saving features. In a Vision Expo West survey, eye-care professionals listed the favorite timesaving features of multiple EHR systems as: flexibility and remote access to files, quick access to patient records, including past office visits; free text type feature to add notes to patient encounters; pre-built exam templates customizable boxes, auto-fill options and drop downs; cloud-based practice management software that allow quickly pulling up the physician’s schedule to make sure patient visits run on time, etc. 5. Don’t strive for perfection: If you are a die-hard box-checker or perfectionist, completing EHR tasks will take forever. Document only what’s needed based on the EHR documentation guidelines and check only those boxes that are essential. 6. Don’t go into lengthy explanations: The AAFP explains: “The clinical note serves as neither biography nor ethnography. Be brief and focused. In the plan section of the note, be clear and concise enough that the next person looking at your note will be able to understand your clinical reasoning and follow the plan”. www.medicaltranscriptionservicecompany.com
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7. Track your performance: Time yourself to see how much time it takes for you to complete a clinical note. Then set your goals and work to achieve them. Delays in completing EHR documentation can hinder clinicians’ ability to provide quality coordinated care. Outsourcing medical transcription can ensure timely, accurate, and complete notes as you focus on your patients. Family practice medical transcription services can help physicians manage heavy workloads and ensure that all clinicians engaged in the patient’s care have access to accurate, up-to-date, and complete information.
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