Good charts and proper documentation take time, but technology and scribes can speed the process and improve the quality of documentation.
One of the most common missteps is the lack of “thought process” during the medical decision-making portion of the note, says Fernando G. Mendoza, MD, FAAP, FACEP, medical director for pediatric emergency and chief of pediatrics at Baptist Health South Florida.
“In other words, what was the physician thinking in terms of a particular disease process or differential diagnosis? Why did you do, or not do, any particular testing, imaging, or procedures?” Mendoza asks. “The old adage of ‘think in ink’ is still very true, and this is really what physicians are trained to do — think. It can be cumbersome, time-consuming, and challenging to actually put your thoughts down in a computer note.”
Another pitfall arises with notes that contradict parts of the exam due to note “cloning,” which can occur in templated notes or with keystroke shortcuts. These are the instances when a physician will blindly place a templated physical exam note in the chart, only to realize later, for example, the acute appendicitis patient’s abdominal exam was recorded as “normal.”
“Underdocumentation is also an issue in the ER. This is where the ‘treat and street’ patient chart is relatively sparse, due to the physician’s thought that the patient really wasn’t that sick,” Mendoza says. “This becomes an issue when the patient returns 12 or 24 hours later with a worsening of the condition. Substandard charts delay the path to timely and accurate treatment, especially for emergency room patients with whom it may very well be a life-or-death situation.”
Focus on ‘Thinking’ Parts
Mendoza’s scribes are trained to focus on the most important “thinking” parts of the chart to accurately reflect the nuanced approach physicians take when treating their patients. The scribes also are trained to avoid charting language that is inconsistent, and to ensure that pertinent positives and negatives of the exam are documented appropriately.
“In the haste of being attentive to patients and providing intuitive bedside manner, physicians today are spread thin and don’t really have the time to chart the last visit when the next patient is waiting,” Mendoza says. “If the physician chooses to chart all their interactions at the end of the day, that opens the door to forgetting essential details of each visit or creating an otherwise inaccurate chart.”
Scribes can help address that problem by charting in real time to alleviate the time pressure on the physician.
“As a director for several emergency departments, I review all high-risk medico-legal cases within our departments. Instances in which a physician failed to document their thought process of why they did or did not pursue a specific course of action is the common theme for all the cases. In other words, just a few lines of “why did I do what I did” would suffice to support the physician’s case,” Mendoza explains. “That, and the occasional contradiction in the physical exam findings with the final diagnosis are the most common reasons. With an added layer of attention to detail and documentation integrity, these cases may have turned out differently.”
EHRs and other charting technology can help improve documentation, but a common mistake organizations make is to place the burden on clinicians to stay up to date on software in addition to their other responsibilities, says Khadim Batti, co-founder and CEO of Whatfix, a company in San Jose, CA, that provides support for digital platforms.
“Beyond clinical work itself, many of these professionals must engage also in continuing education and/or management duties, to name only a few items,” Batti says. “Organizations must take it on themselves to reduce the IT burden on their clinicians so they can focus on patients and improving healthcare outcomes.”
Documentation has emerged as a primary driver of clinician burnout, Batti notes. It is clear that improving documentation systems is paramount not only to the organization’s success, but clinicians’ own health and ability to continue practicing.
“Because software and electronic health records are now a permanent feature of the healthcare environment, it becomes critical for organizations to eliminate as much as possible the friction practitioners encounter when using these tools,” Batti says. “Implementing AI guidance tools that integrate with existing software to autofill relevant information and provide contextual guidance within the flow of work is a primary way organizations are achieving this.”
SOURCES
- Khadim Batti, Co-founder and CEO, Whatfix, San Jose, CA. Phone: (800) 459-7098.
- Fernando G. Mendoza, MD, FAAP, FACEP, Medical Director, Pediatric Emergency, and Chief of Pediatrics, Baptist Health South Florida, Miami. Phone: (833) 692-2784.
Good charts and proper documentation take time, but technology and scribes can speed the process and improve the quality of documentation.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content