Over the past few years, technology has done wonders in the field of medical record documentation. The process has become faster and more convenient, indirectly improving patient care.
Documenting accurate patient health data promotes quality assurance. When a doctor looks at a medical record, he will make better decisions about which procedures, treatments, and medications are best for the patient. When medical practice charges a patient for a medical procedure, the medical record is a document that shows that the procedure has taken place.
Data integrity is of foremost importance because it finds and tracks patients as they move through distinct levels of health care. It ensures that every patient receives proper care that matches their symptoms and past medical history. It also supports the patient billing process. A study by Health Affairs showed that doctors spend as much time working behind the desk every week as they do in seeing patients. A large amount of this work includes patient charting and documentation of their health details
close up of doctor sitting hands holding stethoscope
What is charting in the medical field?
Medical charting is the process of tracking all interactions with patients in a clinical setting. Each patient has a medical chart that records a variety of information by care providers who interact with the patient. Caregivers can use a medical chart to identify allergies, risk factors for various diseases, and other issues that are relevant to current treatment.
The patient’s chart most often holds:
- Patient’s medical history.
- Laboratory reports.
- List of medications.
- Results of physical examinations.
- Consultations, and special diagnostic tests.
- Patient’s response to surgery and treatment.
Effective ways to improve your electronic health record (EHR) charting
Here are five effective ways you can practice medical charting to make the charting process efficient, effective and result oriented.
Make EHR Charting a Team Project
Charting on your own takes it longer to get the job done. Instead, involve your staff and make it a team effort.
Do not be afraid to get everyone involved in the charting process. Nursing staff and medical assistants can document medical information such as vital and patient history, saving your doctors valuable time. The key is to make sure you identify everyone who should contribute to the patient chart and provide adequate training.
Get the Patient Involved
By involving your patient, you can avoid staff being overwhelmed and potentially jeopardizing patient care.
Today patient portal applications allow patients to update vital information including their health history and key demographics, such as their age, race, and ethnicity.
So, it is important to let your patients lend a helping hand and fill out their information through the patient portal.
Automate the Charting Process
Today many EHR systems enable the customization of charting templates. Use time-saving tools to make automation a routine part of the charting process.
This allows physicians to save time because they can complete the chart with a few clicks. Ensure that you follow up with your patients’ charts and personalize them to fit the needs of each visit.
Document Only What You Need
Staff should only be documenting essential information. Providing good training and communication about the information you need during a typical visit will help your employees use their chart time wisely.
Immerse yourself in your EHR
Put effort into studying your EHR.
Study, assess, and implement the functionality and information of your EHR in a thorough manner. Utilize training programs to better understand the product you have invested in to improve the efficiency of your practice.
Doctors are often exhausted by time-consuming tasks, such as entering the same information twice, increasing the risk of human errors. Fortunately, EHR removes this obstacle by delivering customizable templates, so medical practices can customize their workflow to fit their specific needs, allowing doctors to focus more on patient care and less on paperwork.
To take advantage of the full potential in your EHR system, you need to know it inside out.
Ways to improve your charting process
While it is important to streamline the inefficiencies surrounding a patient visit, most of the time these solutions do not result in significant improvements. The biggest issues with seeing patients efficiently throughout the workday have to do with the documentation process and the EHR.
Statistically speaking EHR related administrative tasks account for 30-50% of a physician’s workday, and most doctors spend around 3.5 hours per day on medical documentation.
Some ways to see patients more efficiently are as follows:
- Using note templates
- Partnering with your EHR vendor to adopt best practices
- Hiring medical staff/ Nurse to streamline your workflow
- Make sure to document during the patient visit
- Automate your Medical Notes with AI (Artificial Intelligence)
Doctors are often exhausted by time-consuming tasks, such as entering the same information twice, increasing the risk of human errors. EHR charting makes the process faster and more convenient. The main purpose of EHR charting is its ability to contain treatment plans, diagnoses, medical history, medications, allergies, immunization dates, lab and radiology results of all patients in one place. The ability to deliver data when needed by the providers or their clinical team makes charting very crucial and the cornerstone of a successful workflow.
Following these EHR documentation tips, care providers can leverage them to deliver better patient outcomes, manage their documentation, mitigate burnout, and maximize reimbursement.