5 tips to improve clinical documentation

The clinical documentation processes that physicians follow are arguably as important as their interactions with patients. When doctors take accurate notes, they are helping to increase communication in their practices and provide better continuity of care, as well as improving claim reimbursement and decrease the chances of a physician queries. Many large healthcare organizations have begun to invest in automated solutions to help improve clinical notes. However, there are a number of steps that smaller physician practices can take to help ensure more accurate documentation.

1. Define professional standards
The first step toward better clinical documentation is for a practice to create guidelines for note taking that align with industry standards. The American College of Physicians (ACP) recently released a report that detailed various ways that medical providers can improve their documentation. The authors stated that practices should define guidelines based on "consensus-driven professional standards unique to individual specialties." They recommended that physicians prioritize clarity, brevity and the needs of other readers when developing practice guidelines.

2. Expand education
Some practices may assume that new staff members understand documentation standards, but knowledge of these skills can always be improved. The Healthcare Financial Management Association explained that healthcare organizations will benefit from providing structured training on clinical documentation to new and existing employees. The education process should be ongoing and be adapted whenever electronic health record software upgrades are implemented. When training is a consistent part of a practice's day-to-day happenings, staff members will be well versed in best documentation practices and able to quickly correct any problems.

3. Create peer-to-peer support systems
Nominating a physician leader to spearhead documentation improvements is often a good way to reduce reliance on EHR vendors or third-party trainers. When there is a staff member who knows the ins and outs of best documentation practices, a peer-to-peer support system will be created. This individual should be dedicated to the cause and able to keep up with new developments in note taking. He or she will become a go-to person when physicians or support staff have questions and can help get the office on the same page when it comes to documentation.

4. Review information
It may seem like a no brainer, but taking a few minutes to review the accuracy of past documentation can be extremely beneficial in improving overall accuracy of EHRs. When physicians take time to quickly validate notes with patients, they can catch small errors that may still be on file.

"Ready review of prior relevant information, such as longitudinal history and care plans as well as prior physical examination findings, may be valuable in improving the completeness of documentation as well as establishing context," the ACP report stated.

This practice may interrupt the traditional workflow of physicians, but if it becomes part of their everyday routine, any lost productivity can quickly be regained.

5. Allow patients greater access to EHRs
It is inevitable that physicians will make documentation mistakes from time to time, and who is better qualified to catch these errors than patients? The ACP report noted that when patients are able to review their medical records, they often find inaccuracies that could be substantial in optimizing treatment. By allowing patients to view their EHRs via online portals, practices may be able to improve their documentation and reap the benefits associated with thorough and accurate notes. This type of information access is a required part of Stage 2 Meaningful Use, so many practices may already be working on implementing the technology.

Kevin McCarthy's picture

Kevin McCarthy

Industry News Editor

An avid traveler and news junkie, Kevin covers a range of topics from healthcare technology to policy and regulations. As a former journalism student, he enjoys finding stories relevant to small practices and is passionate about keeping them informed. Before joining NueMD, Kevin worked for Turner Broadcasting as a Programming Intern where he conducted legal research and contributed to editorial content development. He received his bachelor's degree in Communication from Kennesaw State University and currently serves as the Industry News Editor at NueMD.

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