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Top Challenges in Catching Up on Patient Documentation and How to Overcome Them

by Suzanne Quinson | Aug 07,2023
Top Challenges in Catching Up on Patient Documentation and How to Overcome Them

Impact of Incomplete Patient Documentation on Healthcare

Different types of documentation, including patient histories, clinical findings, diagnostic test results, preoperative treatment, operation notes, and discharge summaries, are included in medical records.

For busy healthcare providers, completing patient paperwork on time is a significant problem. Due to the switch from paper-based charting to electronic health records, this is even more difficult (EHRs). While a medical transcribing service provider can offer thorough assistance for the compilation and upkeep of medical records, observing best practices can help physicians finish charting on schedule.

The majority of the time spent using EHRs by physicians in the U.S. was spent on chart review (33%), documenting (24%), and ordering (17%) tasks, according to a study that was published in Annals of Internal Medicine in 2020. Because of the possible impact on patient care and the high expenses associated with this time, particularly for medical experts, researchers indicated that the amount of time that physicians spend utilizing EHRs to support the care delivery process is a cause for concern.

Based on an estimated 100 million patient visits with an estimated 155,000 doctors across 417 health systems, the study was conducted.

In the U.S., doctors used EHRs on average for 16 minutes and 14 seconds per session, with chart review (33%) and ordering (17%) features taking up the majority of that time, according to a study that was published in Annals of Internal Medicine in 2020. The length of time that clinicians use EHRs to support the care delivery process is a worry, according to researchers, because of its possible impact on patient care and the high expenses associated with this time, particularly for medical specialists. The study was based on data from 417 health systems' with about 100 million patient contacts with approximately 155,000 doctors.

Technology Solutions for Streamlining Patient Documentation:

Charting in the exam room using the EHR: 

The main advantage of finishing paperwork in the exam room, besides punctuality, is correctness. When you take or dictate notes, read them aloud as you talk about the patient's medical history, treatment plan, and medication reconciliation. Speaking your dictation aloud will interest the patient, enhance comprehension, and guarantee accuracy. Patients can receive a printed summary of their visit, along with any prescriptions and referrals, by having real-time EHR documentation. For complex patients, record essential findings in the EHR before returning to the patient record later in the day to document the encounter in greater detail.

Obtain assistance with the documents:

The documentation process might be sped up by involving your care team. Have a nurse or medical assistant record the results of the patient's care, go over the medicine, and confirm or note any allergies. After rapidly checking this information for accuracy, you can sign the note.

Specify only what is required by medicine:

The AAFP states that in order to ensure prompt and correct documentation, knowledge of the most recent Evaluation and Management (E/M) criteria is crucial. In January 2021, new standards and coding rules for outpatient E/M CPT 99202-99215 office visits were established. No longer considered in the selection of the code are the past and/or physical examination. Medical professionals have a choice as to whether to base their documentation on medical decision-making (MDM) OR the overall time spent on the encounter's day.

Utilize the time-saving features of the EHR:

EHR systems have a number of time-saving features. In a survey conducted at Vision Expo West, eye care professionals identified their preferred time-saving features of various 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 patients encounters; pre-built exam templates customizable boxes, auto-fill options, and drop downs; cloud-based practice management software that allows quickly pulling up the doctor's schedule to ensure that patients are seen on time; and pre-built exam templates with customizable boxes, auto-fill Templates are helpful for normal visits with typical clinical questions, but manual typing or mobile dictation may be faster in complex or changing circumstances.

Avoid trying to be perfect: 

If you are a rigid box-checker or perfectionist, finishing EHR chores will take an eternity. According to the EHR documentation rules, only record what is necessary, and only check the items that are absolutely necessary.

Avoid lengthy justifications:

The clinical note serves neither as biography nor ethnography. Be succinct and direct. Be succinct and precise enough in the plan part of the letter so that the person who reads it after you will be able to comprehend your clinical reasoning and follow the plan.

Monitor your progress:

See how long it takes you to finish a clinical note by timing yourself. Set goals, and then work toward achieving them.

The ability of clinicians to deliver high-quality, coordinated treatment might be hampered by delays in completing EHR documentation. When it comes to finishing your EHR notes quickly, these tactics can really help.

Documenting in the exam room does have one drawback, though: it may divert attention from the patient. While you concentrate on your patients, outsourcing medical transcribing can guarantee timely, accurate, and full notes. Services for family practice medical transcribing can assist doctors in managing their busy schedules and guarantee that all healthcare providers involved in the patient's treatment have access to correct, current, and comprehensive information.