Charting on patients has become such a large part of what a medical provider does during the day. In the not so recent past, medical charting wasn’t such a significant time drain.
As more and more Medicare advantage plans developed and collecting data became important to insurance companies, the burden of data collection shifted to the provider.
A study in the Annals of Internal Medicine stated that physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time.
Many nurse practitioners, doctors, and physician assistants working in the nursing home spend more than 17 minutes preparing our notes and documenting.
Therefore, it’s more important than ever to work smarter, not harder, when it comes to charting.
Let’s start with the basics.
There are two types of documentation when in the nursing home.
- Paper notes.
- Electronic health record.
Electronic health records can be broken down into whether you use the EHR provided by your employer or the facility. Even if you are charting in the electronic health record provided by your company, most facilities will want a copy of the note in their system.
We know that electronic health records are the future of medical documentation. Now we need to learn how to become better, faster, and produce better quality notes. We will also include some tips for improving paper notes along the way.
Main tips for becoming more efficient at documentation include:
- Utilizing macros and templates.
- Use dictation software
- Write typical phases and statements on paper note first, then make multiple copies for your notes for the day
- Utilize bullet points in your progress notes instead of paragraphs
- Memorize the nursing home CPT codes and what is required for each level
- Do NOT over document
- Use approved abbreviations
- Document the work you do for the visit briefly
- Try to document the same style each visit
- Document for the level of work you do
- Level 99310 has the greatest chance of being audited, so spend the time getting all the components in your note.
- Quote the nursing notes in your HPI when they fit the reason for the visit
How to write medical notes faster
There is a big difference between being thorough and excessive in your documentation. It is even more complicated to include everything regarding the patient in perfect order and form.
Sometimes visits will require more extensive time talking to families, doing a lot of counseling, and more. This extra time would be in addition to the evaluation and treatment of the patient. You could include this time in determining the level of the visit.
However, you will need to make sure that you document the time and how your time was utilized in your note.
Part of effective documentation and becoming more efficient is properly setting up your day for success.
You can do certain things to improve your chances of success, such as;
-Finding quiet places to work
-Having an efficient electronic health record
-Educating staff on when to update you and when to leave you alone
-Getting tools such as dictation software.
Remember, you do not get extra credit for using complete sentences, perfect spelling, and punctuation in the progress note. This doesn’t mean your note should be a grammar mess, but you don’t need a perfect structure note.
Utilizing macros and templates
Most electronic health records have “macros” that trigger a larger paragraph or more words.
There are typed macros and verbal macros. When you type in a predetermined phrase or words with typed macros, it will trigger the EHR to populate the paragraph you pre-typed.
The only difference with a verbal macro is a “spoken” phrase will trigger the EHR to put in the paragraph or words.
By utilizing macros, you avoid having to type what you have in your macro. You could save yourself a lot of time even if you are a fast typist.
Utilize Dictation software
One of the best time savers for improving your speed of documentation is using a dictation program. The more you use the program, the better they work. Eventually, you will be able to dictate a note much faster than you could ever type.
Of course, finding the right program is half the battle. Any can be expensive and cost-prohibitive. If your company can provide this service, take advantage and practice using the service.
There are a few paid dictation software programs.
You can click on the link below if you would like more information on Dragon dictation products.Visit the Nuance store today
There are also free options that you can utilize to speed up your documentation. Some of the easiest ones are integrated into the iPad, Microsoft Word program, and Gmail keyboard app (Gboard)
This is not an extensive list, so do your research regarding the best dictation software.
Utilize bullet points in your notes instead of paragraphs
Many providers struggle with limiting what they document. They will write long paragraphs or full descriptions of what is going on. Schools teach providers “what doesn’t get written doesn’t get done.”
What the schools don’t tell you is you don’t need to include everything in long form. You can utilize bullet form or short statements.
By utilizing shortened form writing, you will complete your notes faster without as much documentation.
Memorize the nursing home CPT codes and what is required for each level
How can you know what to document if you don’t know what each level of CPT code requires?
You need to know how many elements are required for an HPI (history and physical), review of systems, physical exam, assessment, and plan.
You do NOT need to exceed what is required to meet the CPT code criteria. Only include extra documentation if it improves the care of the patient.
Use approved abbreviations when documenting on paper
If you are completing a paper note, it is crucial to cut down on writing whenever possible.
It may not sound like much, but it saves you from writing the entire word if you use abbreviations. Over time, all the reduced time writing will accumulate.
It’s the combination of all the abbreviations that save you time in documentation over time.
Only document for the level of work you do during the exam
I often see providers spending all this time with chart reviews, writing, or typing up every exam detail, lab/study, and more.
However, it would help if you took it one more step. It would be best if you spent level 99308 work/time when doing level 99308. Try not to spend more time that is necessary based on the level of visit.
If you are spending more, it is likely a level 99309 or spending too much time on the visit.
Spend the time on level 99310 CPT coding
One of the areas I recommend spending more time on documentation is when completing a level 99310 visit. This is when you want to spend time meeting all the components of this code.
The 99310 has a higher chance of triggering an audit. Even though there is a higher chance of an audit, it does NOT mean you shouldn’t utilize this CPT code. Just make sure you meet all the exam components when the visit fits the level of care.
You can still use abbreviations, bullet points and stick with the main points of the exam. You don’t have to put in extra time just because it’s a higher level. You put in the extra time to make sure you complete the visit correctly.
Whenever possible, do some charting at the bedside or at the nursing unit that the patient is assigned. Charting on the unit can be a challenge for many because of the many interruptions at the nursing station. However, you will be able to remember things that are fresh on your mind. It can sometimes be very easy to mix up the patients when you take your charting home.
Charting at the bedside is easier when you use paper notes rather than electronically. Use a clipboard to hold your note, take a few minutes to sit with the patient and chart while talking. The patient will feel like you spent more time with them, leading to increased patient satisfaction.
Avoid taking work home.
Whenever possible, try to avoid taking your charting work home. If you can finish your notes before leaving the facility, this will lead to a much better quality of life.
As difficult as this may be, there are benefits to charting in the facility.
You will have access to the patient charts and the nurses involved with the patient’s care.
When you go home, you must rely on your memory and the notes you have taken previously. You are basically charting twice, first taking notes when seeing the patient, and second when you get home to complete your notes.
Some people say that if they did all their documentation in the facility that they would never leave. However, I can promise you that over time, you will become more proficient in your documentation skills and complete the majority of your notes while in the facility.
Find a quiet place to sit.
One of the main reasons medical providers say they chart at home is to avoid interruptions from staff and families.
Finding a nice quiet private place in the facility allows you to maintain access to the charts and staff and avoid interruptions. Finding a quiet place also enables you to have a nice quiet area to concentrate on getting your notes done.
Sometimes the home setting can be just stressful and have multiple interruptions from friends and family. Maybe the latest Netflix episode is calling out your name.
If you’re lucky enough to have an office in the nursing home to work out of, create a sign that says “busy” or “Do not disturb” and hang it up when you’re doing your documentation.
Group your patients
Grouping your patient visits is a trick learned at a former job waiting tables in a restaurant.
Instead of getting up seeing one patient, returning to charting on that patient, then getting up to see another patient, you set up a rounding list of everyone needing evaluation on that unit.
Then round on the list of patients as if it was one big group. Once you evaluate each patient, taking notes along the way, you return to your quiet place to chart and finish your note.
Try to avoid the ping pong of going from floor to floor. Try to finish all the patients on that one unit before leaving for another nursing station. Of course, this is not always possible if somebody has an acute flare-up or had a fall with injuries that may require immediate evaluation.
Remember that each interruption could lead to mistakes in your charting, so it’s best to complete notes before leaving the unit. When you see all the people in the group, complete each progress note, then move on to the next nursing unit.
Educate the staff in the nursing home
Part of setting yourself up for success is getting the staff to buy in to utilize the communication book for reporting issues and concerns.
Many people get multiple interruptions from staff for “updates” on residents that could be written in the communication book.
When you’re documenting and keep getting interrupted, it’s very challenging to refocus. If the staff knows not to call you for every issue, this will free you up to focus on your documentation.
Documentation at home
Unfortunately, some facilities will just not be suited for completing your documentation. The reason could be the constant interruptions from staff patients and family members.
There could also be overhead pages by staff for you to handle certain issues in the facility. Most of these pages are not emergency and could be written in the communication log for the next day.
Either way, the documentation still needs to get done, and some facilities aren’t a good setting for documenting.
One workaround is to start your notes while in the facility and add pertinent information such as vital signs, medications, basic history and physical HPI, and certain things that you do not want to forget.
This way, when you go home, you’ll only have to fine-tune your note, adding in whatever has been missed.
Document as much of what you did to help justify the time.
In our haste to complete the progress note, we do not want to overlook key components of the exam, in addition to the following.
Be sure to include the following extras in your progress note to reinforce the level of visit:
- Time spent reviewing charts
- Talking to family and patients
- Making Appointment or assisting
- Calling specialists to coordinate care (try to include names)
- Updating attending physician
- Discussing plan with family/patient/nurse
- Other tasks involved in the care of the resident
- Time spent reviewing charts, medication, reconciliation
- A brief overview of what was discussed during counseling
Even though there are ways to speed up your medical documentation, you will still need your documentation to be thorough and high quality. You do not want to cut corners when it comes to documenting the necessary components of your exam.
In future articles, we will discuss what’s to improve the quality of your documentation. For now, try to increase the speed and efficacy of documentation so that you can get home to your family at a decent time.
Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility. 2019. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56712 Retrieved October 14, 2021
CPT CODE 99309 SUBSEQUENT NURSING FACILITY CARE, Fact sheet. 2019. https://www.cgsmedicare.com/partb/mr/pdf/99309.pdf retrieved on October 14, 2021
J.M. Overhage, D. McCallie Jr. Physician Time Spent Using the Electronic Health Record During Outpatient Encounters. A Descriptive Study. Annals of Internal Medicine. Retrieved October 14, 2021