Impact of Incomplete Patient Documentation on Healthcare
Medical records encompass various types of documentation, including patient histories, clinical findings, diagnostic test results, preoperative care, operation notes, and discharge summaries.
For busy healthcare providers, timely completion of patient documentation poses a significant challenge. This challenge is further amplified by the transition from paper-based charting to Electronic Health Records (EHRs). While a medical transcription service provider can offer comprehensive support for the compilation and maintenance of medical records, adherence to best practices can aid physicians in completing charting on time.
According to a study published in the Annals of Internal Medicine in 2020, physicians in the U.S. spent most of their time using EHRs on chart review (33%), documentation (24%), and ordering tasks (17%).
The researchers expressed concern over the amount of time physicians spend using EHRs to support the care delivery process due to its potential impact on patient care and the high costs associated with this time, especially for medical specialists. The study was based on an estimated 100 million patient visits with approximately 155,000 doctors across 417 health systems.
Technology Solutions for Streamlining Patient Documentation:
1. Charting in the Exam Room Using the EHR
The primary advantage of completing documentation in the exam room, apart from timeliness, is accuracy. When taking or dictating notes, read them aloud as you discuss the patient’s medical history, treatment plan, and medication reconciliation. Speaking your dictation aloud engages the patient, enhances understanding, and ensures accuracy.
Patients can receive a printed summary of their visit, along with any prescriptions and referrals, through 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.
2. Obtain Assistance with Documentation:
Involving your care team can expedite the documentation process. Have a nurse or medical assistant record the results of the patient’s care, review the medication, and confirm or note any allergies. After quickly verifying this information for accuracy, you can sign the note.
3. Specify Only What is Required by Medicine:
The AAFP states that to ensure prompt and accurate documentation, knowledge of the most recent Evaluation and Management (E/M) guidelines is crucial. In January 2021, new standards and coding rules for outpatient E/M CPT 99202-99215 office visits were established.
The past and/or physical examination are no longer considered in the selection of the code. Medical professionals have the option to base their documentation on medical decision-making (MDM) OR the total time spent on the day of the encounter.
4. Utilize the Time-Saving Features of the EHR:
EHR systems offer several 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 patient encounters; pre-built exam templates with 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 options.
Templates are helpful for routine visits with typical clinical questions, but manual typing or mobile dictation may be faster in complex or changing circumstances.
5. Avoid Striving for Perfection:
If you are a rigid box-checker or perfectionist, completing EHR tasks will take forever. According to the EHR documentation rules, only record what is necessary, and only check the items that are absolutely necessary.
6. Avoid Lengthy Justifications:
The clinical note is neither a biography nor an ethnography. Be concise and direct. Be succinct and precise enough in the plan section of the note so that the person who reads it after you will be able to understand your clinical reasoning and follow the plan.
7. Monitor Your Progress:
Time yourself to see how long it takes you to complete a clinical note. Set goals, and then work towards achieving them.
Delays in completing EHR documentation can hinder clinicians’ ability to deliver high-quality, coordinated care. These strategies can be highly beneficial when it comes to completing your EHR notes quickly.
However, documenting in the exam room does have one drawback: it may divert attention from the patient. While you focus on your patients, outsourcing medical transcription can ensure timely, accurate, and complete notes. Family practice medical transcription services can help doctors manage their busy schedules and ensure that all healthcare providers involved in the patient’s care have access to accurate, current, and comprehensive information.