Medical record management has evolved over time. Previously, doctors would dictate their notes, and a medical transcription service would convert these oral reports into handwritten or typed notes.
With the advent of Electronic Health Records (EHRs), medical transcriptionists now review and edit draft EHR reports written by doctors, eliminating errors, providing clarifications, and enhancing accuracy. However, note clutter and copied notes in EHRs have become a significant issue across all medical specialties.
Healthcare necessitates the documentation of patient interactions. Clinicians maintain clinical data for various reasons:
For healthcare to function, interactions with patients must be recorded. Clinicians continue to keep clinical data for a variety of reasons, including:
- To communicate with other doctors and aid in recalling what was discussed and done during the patient’s visit.
- To defend against allegations of misconduct.
- To involve patients in their own care and demonstrate that quality care was provided.
- To receive payment for services rendered.
The problem arises when the need for comprehensive and appropriate documentation to meet regulatory requirements results in excessively verbose and illegible notes that serves no purpose.
Reasons for EHR Note Bloat:
Medical records document a patient’s history. This allows doctors to review historical data and share information with other healthcare professionals involved in the patient’s care. To accurately record patient history and dictate notes, doctors must be concise, thorough, and empathetic.
In the past, doctors or their medical transcription service would complete the preparation of the notes after the patient’s visit.
Note bloat in an EHR system occurs when physician clinical notes contain too much extraneous material, often obscuring or hiding crucial or urgent information in the patient’s record. EHRs now require doctors to document a significant amount of data during an office visit, even while examining the patient and conversing with them.
EHR systems offer clinicians several time-saving documentation options, including dictation, templated pull-down menus, direct keyboard entry, interfaces with auxiliary systems, and automatic text generation or copy-paste. However, these can lead to confusion and unnecessary documentation. While copying and pasting saves time, it also carries risks.
Factors contributing to note bloat include:
- Evidence supporting the patient’s claim to their insurance provider:
Providers unfamiliar with coding rules may end up incorporating more clinical data to support higher value billing codes, even though capturing more information may not enhance patient care. The Centers for Medicare & Medicaid Services (CMS) have updated the guidelines for office-based Evaluation and Management services to reduce the amount of required documentation, decrease note bloat, and improve code selection.
- Achieving productivity targets:
Due to the significant increase in paperwork and administrative responsibilities, doctors are now using copy-paste and auto-populate features to include more material than necessary.
- Fear of legal action:
Healthcare professionals often write lengthy clinical notes out of fear of missing something that could lead to litigation. In the event of a lawsuit, all data can be submitted in one place “to show all Ts were crossed and all Is were dotted.” However, when previously recorded pointless and unreviewed peer notes accumulate, the medical results can be obscured, and the doctor may end up losing the case.
How to Avoid Note Clutter?
Note bloat impedes effective, compliant clinical record-keeping and can degrade the standard of care. Experts suggest several methods to prevent note bloat:
- Focus on conveying relevant information at that precise moment:
ccording to a For the Record article, clinical notes should describe the clinical situation to the care team, offer suggestions and opinions regarding a care plan, and explain why that plan is the best option at the time. The note should focus on what is happening that day and what needs to be done next, while also considering the patient’s history and previous treatment plans. The note should indicate whether or not a problem has been addressed.
- Training:
EHR documentation training can reduce the amount of time doctors spend inputting data into the system while simultaneously improving documentation accuracy.
Clinicians can increase the accuracy of their documentation and coding while realizing the full potential of the EHR, enhancing productivity and user satisfaction.
- Enhance the template design:
Research suggests that modifying the EHR template can improve record-keeping and reduce the number of unnecessary notes. A study in the Journal of Hospital Medicine found that using a newly created best practice progress note template for daily progress notes allowed physicians to write notes more quickly while also improving the quality and length of EHR notes.
EHR notes are crucial in assisting doctors in making critical decisions regarding care plans, codes, billing, and many other aspects. Primary care doctors may spend less time conversing with patients if they must continually look at a computer screen to take notes.
Family practice medical transcription services are the perfect solution to this problem. With professional help, doctors can focus on the patient while maintaining documentation standards.
Contact www.itranscript360.com for a stable medical transcribing management.