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. <\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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. <\/p>\n\n\n\n
Many nurse practitioners, doctors, and physician assistants working in the nursing home spend more than 17 minutes preparing our notes and documenting. <\/p>\n\n\n\n
Therefore, it’s more important than ever to work smarter, not harder, when it comes to charting.<\/p>\n\n\n\n
Let’s start with the basics.<\/p>\n\n\n\n
There are two types of documentation when in the nursing home.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Main tips for becoming more efficient at documentation include:<\/strong><\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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. <\/p>\n\n\n\n
However, you will need to make sure that you document the time and how your time was utilized in your note.<\/p>\n\n\n\n
Part of effective documentation and becoming more efficient is properly setting up your day for success. <\/p>\n\n\n\n
You can do certain things to improve your chances of success, such as;<\/strong><\/p>\n\n\n\n
-Finding quiet places to work<\/strong><\/p>\n\n\n\n
-Having an efficient electronic health record<\/strong><\/p>\n\n\n\n
-Educating staff on when to update you and when to leave you alone<\/strong><\/p>\n\n\n\n
-Getting tools such as dictation software.<\/strong><\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Utilizing macros and templates<\/strong><\/p>\n\n\n\n
Most electronic health records have “macros” that trigger a larger paragraph or more words. <\/p>\n\n\n\n
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.<\/p>\n\n\n\n
The only difference with a verbal macro is a “spoken” phrase will trigger the EHR to put in the paragraph or words.<\/p>\n\n\n\n
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. <\/p>\n\n\n\n
Utilize<\/strong> Dictation software<\/strong><\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
There are a few paid dictation software programs.<\/p>\n\n\n\n
-Dragon Dictation <\/p>\n\n\n\n
You can click on the link below if you would like more information on Dragon dictation products. <\/p>\n\n\n\nVisit the Nuance store today<\/a>