Ways and Ideas for Efficient Medical Documentation
Quality healthcare is one of the top agendas of many states, and this requires a team of well-trained physicians and healthcare infrastructure. One of the tasks that you will face as a medical practitioner is the entry of medical data of the many patients you see every day. In many health centers, poor documentation is a big issue that should be addressed. According to research, an average doctor spends less of the weekly working hours entering medical records into an EHR. Fortunately, there are ways through which you can boost the efficiency of your medical documentation system so that you can get more time to attend to patients. In many health clinics, you will notice that the use of data entry software has been adopted. Keep reading the article herein to learn how to improve medical documentation.
Delegation can help you ease your medical practice schedule. As mentioned earlier, data entry can consume a significant amount of your time hence you should consider reassigning the time-consuming task. Ensure that you find an individual who is proficient with verbatim transcription of the patient visit and data entry into the EHR. According to the experts, the right professional to hire is a medical scribe, but this can be an expensive approach. The other means to improve efficiency in medical documentation is using dictation software. Once the software capture data, you should ensure that you edit the notes to ensure that they are accurate.
The other way to boost the efficiency of medical documentation is optimizing billing, and this is an acceptable EHR shortcut. Most medical practitioners lose revenue through under coding, and the risk is high if you check the medical records between the patient visits. Also, the risk of over coding is there, and this might lead to insurance penalties. The common causes of under code include lack of full diagnostics, lack of procedural specificity, and missing information. By optimizing billing, you will be sure that no information will be left out. To ensure that you focus on a single task all the time, you should create a time schedule.
Lastly, you should implement the 2-minute rule in your documentation process. The 2-minute rule should be adopted as soon as you understand the idea of monotasking and delegating duties. Using the 2-minute rule, you will get to reduce your workload as you will take care of the tasks that take less than 2 minutes immediately. Everyone finds it had to handle large stressful tasks and the best way to handle them is breaking them into smaller and simpler tasks.
Therefore, as a medical practitioner, you should consider the above-discussed ideas and tips if you want to boost the efficiency of your documentation process.