Tips to Improve Medical Documentation for EHR Integration

Medical documentation is a significant factor in practice inefficiency. On average, healthcare providers work more than 50 hours a week and see around 20 patients daily. With typical patient visits lasting about 15 minutes, this means less than half of their workweek is spent with patients. The remainder of their time is spent in front of a computer, inputting patient information into an EHR.

This situation has led to various methods designed to reduce the time spent on documentation. One common approach is copy-forwarding, where clinicians reuse notes from previous visits and adjust them as needed. A recent study revealed that in a typical note, more than 45% of the content is copied, 18% is manually entered, and 36% is imported from other sources, like a medication list.

Although copy-forwarding may seem like an efficient way to speed up note-taking, it can often be counterproductive due to the higher risk of including outdated or irrelevant information. In 2016, improper payment fees for Medicare exceeded $40 billion, largely due to issues like incorrect coding, inadequate documentation, and the inclusion of unnecessary data.

Copy-forwarding is just one of the strategies clinicians use to spend less time on paperwork and more time with their patients. Fortunately, more effective alternatives exist. Here are four ways to improve your documentation efficiency without compromising the quality of your notes.

9 Tips for Efficient Medical Documentation for EHRs

By following the below given tips, you can significantly improve your documentation process and bring your focus back to patient care. You’ll reduce the time spent on documentation and increase the efficiency of the time you dedicate to it. Here are the tips you should try to use in your practice for effective clinical documentation: 

1. Train Your Team 

If your team is experiencing reduced productivity due to incomplete, inaccurate, or unclear documentation, additional training may be necessary. It’s crucial to ensure everyone in your organization understands the documentation process. For some team members, this may require revisiting the basics. Training should be informed by feedback from evaluating communication and reporting. Addressing any confusion or miscommunication in reporting should be a key focus of training efforts. Your team can also take online courses from AHIMA or other similar providers to improve their documentation skills.

Monitoring documentation and tracking queries is vital to identify if documentation is becoming a bottleneck. With the insights from this article, you should have a solid starting point or new strategies for enhancing healthcare documentation within your organization.

 2. Stop Miscommunication  

A key aspect of improving healthcare documentation is ensuring that all essential information is accurately captured. This includes making sure there is no misunderstanding between those documenting the information and those who will later use it. Even when physicians record crucial details, they lose their value if the documentation leads to constant follow-up queries.

It's vital to maintain clear communication between coders, physicians, and the CDI team within your organization. If problems persist, they must be addressed and resolved promptly.

3. Don’t Overuse Shorthand 

A major result of evaluating communication between these groups is identifying where miscommunication happens. This confusion often arises from the use of unclear or illegible shorthand. Shorthand can lead to errors or misunderstandings because it relies on both parties having the same understanding of the terms being used. To prevent this, it’s important to clarify shorthand terms or avoid using them altogether.

4. Deploy Speech-to-Text AI Medical Scribes 

The time-consuming nature of documentation often leads to incomplete records piling up, and sorting through them at the end of the day becomes a regular task. This can cause errors or inconsistencies, while also taking away from a physician’s personal time. Using speech recognition allows physicians to capture information quickly by speaking, instead of typing it out manually.

SOAPsuds, a cloud-based AI-powered speech recognition tool (Speed-to-text) designed for healthcare providers, helps streamline documentation by using voice commands and automatic shorthand conversions. Many medical professionals are turning to speech recognition to improve the efficiency of their dictations. In some cases, this technology has helped reduce or even eliminate the need for transcription services. Physicians can directly record their dictations and make edits as needed.

5. Effective Task Delegation 

Delegating tasks helps you manage your time better by passing on responsibilities that don't require a medical professional to handle. In medical documentation, tasks like transcribing the patient visit word-for-word, organizing notes, and entering data into the EHR are ideal for delegation.

A common method of delegating documentation is by hiring a medical scribe. However, for many healthcare providers, hiring scribes can be too expensive, with costs reaching around $50,000 per year.

Another option for delegating documentation is using dictation software, which turns spoken words into written text. While this saves time on typing, you will still need to review and edit the notes to ensure they are accurate and complete.

One of the most efficient ways to delegate documentation tasks is by using an AI-powered scribe. Unlike dictation software, AI scribes can manage the entire note-taking process on their own, and they do so at a much lower cost than hiring a human scribe.

6. Maximize Revenue Through Billing Optimization 

Rushing through EHR entries can affect both the quality and accuracy of your documentation, and it can also influence your practice’s financial performance. If you consistently rush through notes between patient appointments, there's a higher chance of undercoding, which could lead to missed revenue, or overcoding, which may result in penalties from insurance companies.

7. Prevent Undercoding for Foolproof Billing 

A significant portion of patient visits, about one-third, are undercoded, which is a common issue that led to losses of up to $1.2 million for healthcare providers in 2016. The main reason for this? Insufficient documentation.

To avoid undercoding and ensure proper billing, be mindful of these frequent mistakes:

•    Missing details: For instance, the date of an accident, emergency, or when a condition began.

•    Incomplete diagnostics: Providing more specific information about the severity of a condition is crucial for receiving full reimbursement.

•    Insufficient procedural details: Document all procedures performed and note any complications that occurred.

If you choose to delegate your documentation to either a human or an AI scribe, these critical details will be captured for you. This means that no information will be overlooked or forgotten, even after a long day of seeing patients or when closing charts later. Before finalizing your notes, take a moment to double-check for these common oversights.

8. Prioritize Monotasking for Increased Efficiency 

When performing repetitive tasks such as EHR data entry, it can be tempting to try and handle another job at the same time. However, each time we switch our focus to something else, like checking emails or replying to text messages, we experience a brief mental pause that can reduce productivity by up to 40%. Additionally, research has found that frequent multitasking can lead to a decrease in the size of the brain’s grey matter, especially in areas responsible for empathy and emotions. This can negatively impact your ability to connect with patients.

So, what’s the alternative? Monotasking, or dedicating your attention to a single task for a specific period of time. One effective way to incorporate monotasking into your routine is to block off time on your calendar exclusively for note-taking. During this period, eliminate all other distractions and focus solely on completing patient documentation.

Start with manageable time slots based on how long you can maintain focus without interruption. Over time, as you practice monotasking, it will become easier. As you get better at it, you’ll notice that you’re able to complete your notes much faster.

9. Implement the 2-Minute Productivity Rule  

Once you get the hang of monotasking and start delegating most of your medical documentation, you can apply the 2-minute rule. This rule, created by productivity expert David Allen, suggests that “If a task takes less than two minutes, do it right away.”

Big tasks can seem overwhelming, but they become much easier to manage when broken down into smaller, manageable parts. Instead of viewing your growing pile of paperwork as a single large task, focus on each individual chart and the specific actions needed to complete them. This becomes even simpler if you rely on an AI scribe, as you’ll only need to review and approve the notes that have been prepared for you.

Conclusion 

Effective documentation is key to improving healthcare efficiency and patient care. By applying these tips, you can simplify the documentation process and enhance the patient experience. Leveraging technology and focusing on quality care allows healthcare providers to better meet patient needs and streamline their workflow.