Electronic health records have drastically changed the way the physician documents patient history, diagnostic notes, surgical reports, and discharge summaries. According to an article published by the American College of Physicians (ACP), digitization can reduce the quality of physician documentation in medical records if EHRs are not optimized to be relevant to the patient’s current situation.
In the conventional method (before the advent of the EHR), documentation was done using a medical transcription service. The physician would dictate the medical history, physical exam findings, and then the overall assessment of the patient condition and the treatment plan. The medical transcription company would then faithfully transcribe the dictation and produce a record that would appear in the chart, with appropriate sub-headings and in flowing paragraphs in a format that resembles a written report.
While medical transcription services are relevant even today, experts point out that the use of the EHR copy-paste function by physicians can affect the integrity of patient information. Copying notes can speed documentation, but whole-note cloning results in information that is not pertinent to the current encounter.
A 2013 ACP Critical Care Medicine study conducted in the medical intensive care unit of a hospital reported that up to 20% of the information in 74% of attending physicians’ EHR notes and 82% of residents’ notes was copied from previous notes. The researchers noted that this led to a lot of confusion as the treating physician would find it difficult to figure out “what was done, when it was done, what the physician’s thought process was, what the next step is going to be.”
Therefore, editing progress notes in EHRs is crucial to ensure that they:
- Contain concise, clear, legible, meaningful information that is accurate and complete
- Provide an accurate record of care
- Give a clear roadmap for the next provider of care
Copying some past notes is necessary to document efficiently. However, the physician has to be alert about repetitive, unedited notes that have been carried over from past entries. These would contain plenty of information, but not necessarily the right information in the right place for the present time. Experts offer the following tips to help physicians better manage information in the main documentation sections:
- Regularly examine their last history of present illness or the results of the last exam and bring it forward into the note if relevant
- Update what has changed or is new, and inform the patient of important changes
- Ensure that the final EHR document is clear and succinct without volumes of unnecessary data
- Include intelligent looking descriptions and paragraphs
- Use tick boxes efficiently
In addition to carefully reviewing and editing any information that is copy-pasted, physicians need to ensure accurate data entry to provide optimal care to their patients. Relying on a professional medical transcription service company is the best way to improve EHR data capture. Leading companies provide customized EHR/EMR-integrated documentation solutions.