Clinical documentation is a critical part of a doctor’s workload. It helps ensure that patients receive quality care and that hospitals and facilities have accurate patient interactions and diagnosis records.
It is a legal requirement for care and a bit part of a physician’s evaluations.
However, clinical documentation is also a huge burden and intensely time-consuming and complex across multiple systems. As a healthcare provider or physician, it’s important to streamline your clinical documentation process as much as possible.
In this blog post, we’ll discuss the benefits of streamlined documentation and outline some tips you can follow in your own practice.
Save Time
Time is a doctor’s most precious commodity. You only get so much in a week. Use it wisely and it will provide days off, time with family, more patients, and higher revenue.
Use it inefficiently and you will work all day then go home and work some more.
One of the most obvious benefits of streamlined clinical documentation is that it can save you and your practice loads of time.
When documentation is streamlined and connected, it’s easier to find the information you need when you need it.
It’s also easier to enter new information. This helps reduce the time spent on creating EHR notes, charting, and documentation overall.
Streamlining documentation using a groundbreaking doctor note generator can allow you to combine billing and charting into a single workflow and complete both of them at the same time in a fraction of the work.
Providers who use electronic health records (EHRs) spend less time per day on clinical documentation.
In addition to saving time for providers, streamlined clinical documentation can also save time for office staff and nurses. When charting is simpler and easier to understand, it can speed up the process of getting patients registered and scheduled for appointments.
It can also help to ensure that billing is accurate and that insurance claims are processed more quickly.
Improve Care Coordination
In addition to saving time, streamlined clinical documentation can also improve patients’ quality of care by allowing providers to track progress and changes across multiple providers when sharing coverage.
With quick and easy access to key patient information right on their phone, they can review progress and make more informed decisions about the next steps in patient care.
They can also make any changes to the treatment plan knowing the next provider in the shared coverage will be able to follow and build on.
This also helps the nurses and mid-levels access accurate and up-to-date information synced directly with the hospital or facility so that everyone is on the same page.
Improve Provider Satisfaction
Streamlined clinical documentation massively improves provider satisfaction.
One of the biggest issues with being a doctor is how much non-doctor work you have to do like billing, data entry, and administrative and clerical work.
Streamlined documentation that is done at the point of care and synced into the note section of the hospital EHR lets doctors focus more of their time and energy on what they do best, practicing medicine and taking care of patients.
When providers have access to the information they need in a fast and organized manner and are able to handle in minutes what used to take hours, they can work more efficiently and effectively.
Additionally, when EHR notes are available easily and on the go, it can help reduce frustration and wasted efforts, ensuring the time they have with the patient is more meaningful.
Providers who use mobile note generators integrated into the EHR of record are more likely to report higher satisfaction levels than those who have to spend 30%+ of their time manually charting in the traditional manner.
Improve Patient Satisfaction
Streamlined clinical documentation has been studied on its impacts on patient satisfaction and the data shows that it impacts variables key to generating higher patient satisfaction scores.
There is a correlation between the quantity and quality of a patient’s time with a doctor and the satisfaction they feel about their care.
Fast quick visits that leave a patient feeling unsatisfied are just as bad as longer visits where they have to repeat things they told other caregivers or reiterate issues that didn’t make it into the chart.
With fast accurate information right at their fingertips, and more time available to spend with the patient because less is being allocated to administrative burdens, providers not only come across as organized and informed but don’t have to rush off or cut visits short.
They are able to spend an extra minute or two answering questions, addressing secondary concerns, checking in on their patient on a personal level, and just making the person feel more comfortable.
Bill and Chart in One Step
Traditionally billing and charting are separate burdens.
Charting is done for legal reasons and to document patient care, and billing is done for financial reasons to get paid for services rendered.
With an integrated note generator and charge capture workflow in one, a provider is able to complete both requirements in the same streamlined step using templates and rules engine parameters to make the process custom fit the context of the encounter.
No answering questions or entering data that isn’t relevant to that patient or visit, no need to re-enter everything every time, and no extraneous clerical burdens.
Just a fast easy process that submits a progress note to the chart while submitting a claim to the biller all done on the phone on the go at the point of care in a third of the time it used to take to do either billing or charting.
Eliminate Redundant Data Entry
Integrating clinical documentation from the charge capture app to the facility EHR can also eliminate redundant data entry.
Typically, many hospitalist practices employ a secondary EHR to take notes and document, then have to transfer that information into the primary EHR, the one of record, which is associated with the hospital or facility the patient is being treated in.
The EHR of the record is the only one that matters legally but it is often hard to chart indirectly, so providers who work exclusively on the go pay costly premiums to use a redundant software system that is easier to use and then transfer the data.
The issue is that not only does this add costs, but increases the risk of data transfer losses or corruption.
With an integrated note generator that has streamlined workflows, a hospitalist can remove the secondary EHR, skip the extra costs and risks, and just save their information directly into the integrated system of record while on the go from a mobile device or from their tablet or laptop.
It syncs in real-time and has two-way capabilities, so anything that updates from them populates into the system and anything someone else updates in the system populates to them.
This eliminates the need for duplicate entries and reduces the risk of errors or issues.
Redundancies are one of the biggest problems with clinical documentation.
They not only take up time but come with other frustrations and risks.
With a streamlined way to complete the documentation processes in a single streamlined process, providers can dramatically improve the overall efficiency of their clinical documentation process.
A Streamlined Clinical Documentation Process Matters
When it comes to patient care, clinical documentation, and even revenue collection, having an integrated documentation solution is a critical piece of the puzzle.
Healthcare providers who invest in mobile integrated progress note software that connects to Epic, Cener, PointClickCare, MatrixCare, eClinicalWorks, or whatever EHR they have to chart in, will see a host of tangible and intangible benefits including more time, better patient care, easier rounds, stronger organization, and better information access.
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