The move from paper to electronic health records has left many physicians spending more time on charting and paperwork than ever before. Most doctors spend over 10 hours per week on bureaucratic tasks, which often leads to frustration and burnout. If this sounds familiar, it’s time to adopt these workflow hacks and consistently complete your clinical notes before leaving the office.
Seven tips for getting clinical notes done on time
These tips are adapted from Colleen Fogarty, MD, MSc, who originally shared them in Family Practice Management. While they speak to physicians without scribes, we also suggest considering modern speech-to-text medical dictation software if you’re serious about efficient documentation.
1. Leverage the skills of your team members
You don’t have to document everything yourself; strategically involving your team can save hours. For example, a nurse or medical assistant can document patient outcomes, review medications, and verify or record allergies. You can quickly review this information for accuracy and sign off on the note.
2. Complete most documentation in the room
When talking with a patient about their health history or treatment plan, summarize aloud as you take or dictate notes. Dictating aloud is efficient and can also engage the patient, improve understanding, and ensure accuracy. Many providers have found that dictating clinical notes during patient visits has improved their documentation workflow in several ways.
3. Know the E/M documentation guidelines
A 99213 level of service doesn’t require a comprehensive review of systems or a comprehensive exam. This code is, by the way, used 61 percent of the time by family physicians seeing Medicare patients. Save time by adhering to the guidelines and only documenting what’s medically necessary to complete today’s visit.
4. Use essential EHR functions
Do you use the time-saving features of your EHR? Templates, for example, are helpful for routine visits where clinical queries are standard. Manual typing – or mobile dictation – may be the fastest in complex or changing situations. But if it’s flu season, save yourself time by creating a basic influenza vaccine template. See more tips on how to optimize your EHR workflow.
5. Let go of perfection
The EHR can be a black hole for perfectionists and compulsive “box-checkers.” Remember the documentation guidelines and keep it simple. Not all boxes need checking, and you don’t need to fill every category each visit. Know what matters and leave the rest alone.
6. Tune the “opus”
When you’re reviewing past notes in preparation for the next visit, jot down on a sticky note if there’s information you wish you had, but isn’t present. After a few days, you might notice some patterns: “expound on mechanism of injury” or “record caregiver’s name.” Your future self will thank you!
7. Time yourself
Use a timer on your smartphone or watch to see how long it takes to complete a note. Knowing your baseline, set a goal to decrease your per-patient documentation time. Speed shouldn’t be your only goal, and spending more time documenting visits with new or complex patients may be valuable.
These tips will help you get through most of your routine documentation faster. Discover more EHR productivity hacks or learn how a mobile dictation solution could shave off hours of documentation time each week.