Clinical Documentation
9 May

Better Clinical Documentation leads to Better Outcomes

EHRs can be a double-edged sword at times. Some systems give you an opportunity to check just the systems that are reviewed and examined but may still print every system and area of exam on your final document. This leads to excessively long clinical documentation where the work you’ve done with the patient gets lost in the details.

This is where taking the time to build clean, user-friendly EHR templates should be a priority for every practice. If you are using “out-of-the box” or “canned” templates that came with the system, your notes probably end up being 4-5 pages long once printed. To a doctor your office sends the records to that you refer a patient, your records may make it more difficult to determine why the patient has been referred.

Multiple Templates

Many providers feel a single template that encompasses all his major patient diagnoses won’t clutter up the system. However, having a separate template for your top five diagnoses will make your templates easier to navigate and the final product cleaner. For example, for Internal Medicine you would probably want High Blood Pressure, Diabetes, COPD, Heart Disease, and Annual Physical templates. This, of course, will vary on location and specialty.

Signing off on your notes

The less cluttered your notes, the faster you will be able to sign off on them. That means charges are ready sooner and claims are created faster. Many systems will not allow you to release charges until the note is finalized.

Coding and Billing

The more concise your note, the easier it will be for coding and billing to review your notes for faster coding and faster follow-up on your Accounts Receivables. Easier coding leads to fewer denials for incorrect diagnosis or CPT codes and fewer requests back from the billing department for an amended note with a corrected diagnosis or CPT code.

Building a template can be time-consuming. However, taking the time up front to think through your different visit types will make your notes cleaner and more concise. And just because you’ve already been on your EHR for several years using the same templates doesn’t mean you still can’t revisit the multiple template notion. You should review your templates at least once a year. You will typically find things you are constantly having to add that are missing from the template that you didn’t think of during the build. It’s never too late to keep improving your note!

Donna White

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