8 Recommendations to Expedite Your Medical Documentation
Completing clinic notes while you’re treating many patients is time-consuming and an epic challenge. Here are some efficiency tips to prevent clinician burnout.
Goals of Documentation
Clinical documentation should have three goals:
- Continuity of care: communicate to the team what’s going on.
- Billing: if it wasn’t documented, it cannot be billed.
- Legal coverage: defense against malpractice.
Use bullet points for concise and accurate documentation. You want to keep it short and simple, and quickly get to the point. Try to use bullet points that are easy to read. Nobody wants to read a novel when reviewing a note.
The average physician typing speed is 35 WPM. Use dictation software to efficiently capture your note and lessen the documentation burden.
Dot Phrases & Templates
Avoid repetitive typing. Why waste your time typing the historical features of a UTI or a cold? Capture the essentials of the visit with minimal effort using dot phrases and templates. Even though they take time to create, it’s time well invested. Discover and create your dot phrases at Chartnote.
Copy-pasting can be hazardous as it could make your note unreliable. Copy-forward on the other hand can be safely used as long as you only copy relevant information and it is meticulosly updated.
Workflows & Pre-charting
Pre-charting, huddling and establishing workflows with your staff can help you speed things up at work. Do a quick chart review and pre-complete most of your note before seeing your patients. Then you can just edit as you go.
Spend a minute finishing your note right after the visit or 10 minutes at the end of the day. Prioritize finishing all your notes before leaving work. Don’t finish your notes at home. Have a healthy work-life balance.
EHR Orders Favorites
It can take up to 62 clicks to complete an order for Tylenol. Save time and effort by saving your favorite labs, meds and imaging orders. This list is a good place to start.
We want to hear from you. Share your tips to expedite your medical documentation. Feel free to comment below.