Medical Record Documentation – Best Practices

Medical Record Documentation

Clear, accurate, legible, complete and accessible medical record documentation is essential to facilitate patient care decisions and avoid treatment errors. Medical transcription outsourcing is considered a viable strategy to promote timely and accurate patient charting. However, it is the healthcare provider’s responsibility to ensure that relevant facts, findings, and observations about a patient’s medical history, including past and current illnesses, tests, treatments, and outcomes are entered in the electronic health record (EHR). Following best practices can make EHR documentation more efficient, contribute to high-quality care, protect healthcare organizations from risk of liability, and also reduce physician burnout.

Basics of Good Medical Record Documentation

  • Document the history and the physical examination: Elicit and document medical history, including history of present illness, chronology, modifying factors, and associated symptoms, past medical history, general health and childhood illnesses, surgeries, hospitalization, trauma, medications, allergies, family history, and social history. Documenting patient history will ensure that past and present diagnoses are available to the treating and/or consulting physician. Proper documentation is critical in emergency situations.

After obtaining the chief complaint and history of the present illness, perform and document the physical examination. The physical exam would depend on the patient’s complaint. The levels of evaluation and management (E/M) services are based on four types of examination: problem focused, expanded problem-focused, detailed, and comprehensive. Documenting the physical examination is required to communicate patient care provided among healthcare providers as well as for justifying medical billing. Whether it’s a single organ system or body area or multiple organs and body areas, document the entire examination. Organ systems, not body areas, should be used to identify the required elements. Finally, consider summarizing key history and physical exam findings so that other providers don’t have to spend too much time reading the notes.

  • Be cautious when using prepopulated EHR templates: Prepopulated physical exam templates enter information into the patient’s record, assuming that normal aspects of the exam were performed. Being conscious of what’s prepopulated is important so that changes specific to the patient can be made. If this is not done, the physical exam documentation may be incompatible with the chief complaint, history of present illness, or the assessment and plan.
  • Avoid indiscriminate use of the EHR copy-and-paste function: Using the copy-paste function to import previous notes into the current encounter has the potential to affect the integrity of the health record as the information may no longer be relevant. It can result in inaccurate coding, transmission of false information, inability to track the patient’s care, and lengthy, redundant progress notes. A cross sectional survey of resident and faculty physicians at two academic medical centers found that inconsistencies and outdated information were common (71%) in notes containing copy and paste text.
  • Document all provider-patient communication: Effective provider-patient communication is key to building a therapeutic physician-patient Physicians and their staff should document all communication with patients outside of the office, including phone calls and emails in their medical record. It is also important to document interactions with relatives/caregivers of patients, other medical teams, and specialists involved in the care of the patient. Summarize the main points of the discussion and who participated.  As Clinical Advisor points out, this crucial to prove that you did not ignore the patient if you are deposed.
  • Promote documentation interoperability and transferability: It is important that pertinent information, including nursing notes, can be sent to other systems in a usable format to other systems. To facilitate interoperability and transferability, a Nursing World report states that it is necessary to use standardized terminologies to describe assessment, identification of problems, diagnoses and interventions, outcomes, evaluation, and recommendations, and also have a system in place to accurately document errors (commission, omission, and near misses) that meet a national standard.
  • Document future plans and objectives: Patients may see providers at other facilities for ongoing or follow-up care. Clinical documentation should communicate plans and objectives to other healthcare professionals such as life care planners, social workers, and specialists, who might care for the patient in the future. Documenting future plans will help ensure that the patient receives the follow-up care needed to fully recover or manage an ongoing condition.

Support Strategies to Improve Medical Record Documentation

Having reliable support strategies in place can reduce the documentation burden, improve productivity, and streamline workflow. Many physicians use dictation software to speed up EHR documentation. But for speech recognition to work, you would have to expand its vocabulary and train it in correct pronunciation. Getting scribe support is another option. In fact, some primary care offices that have limited staff use scribes to help with electronic documentation (AAFP). Family practice medical transcription services are also a cost-effective way to save time, improve efficiency and ensure quality medical record documentation. Experienced transcriptionists can deliver accurate transcripts of the H&P, allergy & immunization, chronic disease management, follow-up visits, and much more. Partnering with a reliable medical transcription service company can help provider focus on their patients, improve compliance, and reduce burnout.