Falling Behind On Patient Documentation? How To Complete It In Time

Patient Documentation

Medical records comprise different types of documentation on patient history, clinical findings, diagnostic test results, preoperative care, operation notes and discharge summaries. Completing patient documentation on time is a major challenge for busy healthcare providers. This is all the more challenging with the move from paper-based charting to electronic health records (EHRs). While a medical transcription service company can provide comprehensive support for medical record creation and maintenance, following best practices can help clinicians complete charting in time.

According to a study published in Annals of Internal Medicine in 2020, physicians in the U.S. spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. Researchers said that the duration of time that providers spend using EHRs to support the care delivery process is a concern, due to its potential effect on patient care and the high costs related to this time, especially for medical specialists. The study was based on approximately 100 million patient encounters with about 155,000 physicians from 417 health systems.

Though EHRs have made charting faster and more complete, they have taken away from patient time. Optimizing systems and processes is therefore essential to ensure proper documentation along with provision of quality care, and importantly, to prevent stress and burnout. Here are seven strategies to complete patient documentation in time, including recommendations from an article published by the American Academy of Family Physicians (AAFP):

  • Do EHR charting in the exam room: In addition to timeliness, the key benefit of completing documentation in the exam room is accuracy. As you discuss the patient’s health history or treatment plan and medication reconciliation, review aloud when you take or dictate notes. Dictating aloud will help engage the patient, improve understanding, and ensure accuracy. By documenting real-time in the EHR, patients can be given a printed-out summary of their visit as well as any prescriptions and referrals. For complex patients, Boston-based pediatrician Michael Lee MD said he documents key findings in the EHR, then revisits the patient record later in the day to document the visit more fully (www.medicaleconomics.com).
  • 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.
  • 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.
  • 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 time-saving 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. Templates are useful for routine visits with standard clinical queries but for complex or changing situations, manual typing or mobile dictation may be the fastest, notes MobiusMD. However, experts recommend using Templates and the copy and paste functions judiciously as they can bring in information that is no longer relevant to the patient’s current condition.
  • 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.
  • 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”.
  • 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. These strategies can go a long way when it comes to getting your EHR notes done quickly. However, there’s one downside when it comes to documenting in the exam room – it can take attention away from the patient. 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.