Many physicians find electronic health record (EHR) documentation tedious as it involves too much time doing data entry which takes away from direct eye contact with patients. Physicians need to document each patient interaction correctly and as soon as possible to maintain the integrity of the record. Medical transcription outsourcing is a feasible strategy to create accurate, integrated and complete digital patient medical records from your notes. Here are some useful strategies you can consider reduce your work load and save time on EHR documentation, including strategies recommended by the American Academy of Family Physicians (AAFP).
- Rearrange your Exam Room: The computer should be positioned in a way that allows you to see both the patient and the screen with just a minimal shift in gaze. The aim should be to avoid any position where you have your back to the patient, as if you do, you could miss crucial nonverbal clues, besides straining your neck! A computer or monitor that swivels or a wireless medical computer workstation on wheels are popular options user-friendly, ergonomic options.
- Use Two Screens for Televisits: For a telemedicine setup, the AAFP recommends two screens – one that shows the patient and another for EHR documentation. You should be able to see the patient and the digital medical record with just a slight shift of your gaze. Consider a tablet to communicate with the patient and a desktop or laptop for EHR display.
- Leverage EHR Capabilities and Hacks: EHR templates are designed to promote structured and efficient documentation of care and eliminate the need to type out words or phrases.
- Use templates for physicals, routine office visits, televisits, procedures, patient instructions, specific exams and health parameters. Insert the automatic list of the patient’s diagnoses and related orders in the template into the assessment/plan and type in only the remaining few details.
- Automatically extract problems and diagnoses from assessments and plans, instead of repeatedly documenting each problem.
- For questions that have options that are short responses that do not need lengthy answers or elaboration, use the form fields or checkboxes. This can help minimize errors, improve understandability, and save time on documentation.
- EHRs also feature shortcuts called smart phrases or dot phrases that save physician time. Learning how to use EHR templates and smart phrases can help you capture the key elements of the visit with minimal effort. Dot phrases can help with proper documentation of common procedures and office visits, manage your inbox, and much more. However, while using these well-rounded phrases, make sure that the action noted in the smart phrase is actually performed.
- Stick to Short Notes: In order to meet billing requirements, physicians tend to write excessively long notes in the EHR, which is not only time consuming, but also leads to “note bloat”. Avoid long notes when documenting the history of present illness (HPI). Document the medical visit clearly using short phrases to identify each complaint. Ensure that you use semi-colons to separate each phrase. Use two spaces and another line to document a separate complaint.
- Use Online Patient Questionnaires to Collect Data: Use questionnaires to collect information from patients for common situations, medical history, current medications, and review of systems. This can save time that would go into asking patients questions during the consult.
- Train your Dictation Software to Increase Accuracy: Dictation systems may misrecognize certain words or commands during your dictation. Make your dictation software more accurate and precise by training it on the correct pronunciation of specific words and commands. You can even train the software to recognize voice commands to add templates.
- Use Copy-paste to Streamline Patient Education: A lot has been said about the time-saving copy-paste function in the EHR and how it can lead to errors that have legal consequences. However, copy and paste feature can be used safely to streamline patient education. Copy paste relevant information from the treatment plan into the patient instructions and save time on typing out the details. Leveraging audio or video patient education materials during the visit can also save time.
Other strategies experts (link.springer.com) suggest to improve the efficiency of EHR documentation include:
- Develop novel ways to update standing lists, so that useless information is removed automatically.
- Include anticipatory guidance in automated recommendations so that the system gets things done before the user does it.
- Try to group related information together.
- Make it easy to find information with a record
- Use techniques that can reduce the number of clicks, including keyboard shortcuts, and make touchscreens available for selected functions.
The AAFP recommends using scribe or team documentation to save time on EHR tasks. Today many primary care practices rely on family practice medical transcription companies for EHR documentation support and also to review prior notes and ensure they are accurate, complete, and free of grammatical errors and typos.