Note Bloat Issues with Identical and Default Text When Using EHR Efficiency Tools

Karthikeyan Babu Karthikeyan Babu

Karthikeyan Babu

Performance Ennobling Agent I Human Behavioral Science Enthusiast

发布日期: 2021年1月29日
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A 2017 study of over 23,000 patient progress notes for one software showed that only 15% of the text was entered manually. The rest was either cut and pasted or “imported”.

The duplication of prior documentation is the start of the process. Whether information is cut and pasted, pulled forward, or entered with a smart phrase, compliance issues exist.

What information IS ALLOWED to be incorporated in another day’s note?

What is allowed from a compliance perspective?

What does your medical record software ALLOW providers to do?

Looking at one patient note may not give a Coder the insight they need about the patient’s record and their provider’s habits with documentation.

Norcal group has some recommendations for Physicians:

  • When a template is used, personalize observations. Do not just rely on the default language provided by the template.
  • If it is too difficult to type up why patients presented for treatment, find a way to dictate crucial information.
  • Think of what you would like to review yourself in a patient’s record and use that as a guide for relevancy.
  • If self-populating templates are unavoidable, go through final record entries and ensure they accurately reflect the patient’s condition and systems you have, in fact, evaluated during the encounter.
  • If the template automatically pulls forward information from past visits (e.g., chief complaint, social history), ensure that the information is still accurate.
  • Make necessary corrections before making your current entries a part of the patient’s permanent record.
  • Know the source of the pre-composed text that is generated by templates.
  • Create varied exam templates for different patient complaints and conditions that fit your practice workflow.
  • Discuss with administrators any problems with auto-populated fields and pre-composed text.
  • Contribute to troubleshooting when appropriate and necessary.
  • Choose an EHR system that does not use templates that automatically generate content for normal findings.
  • Require the user to specifically check off the elements he or she wants to appear in a patient’s record.
  • Carefully design templates.
  • Use a collaborative approach that involves physicians, clinical staff, and representatives from health information management services, clinical documentation improvement, and information technology.
  • Schedule meetings designed to encourage staff and physicians to determine and share EHR best practices with one another.

The Skillful RCM partner is the secret of successful EHR implementation.  

References:  :

Jill M Young, Principal of Young Medical Consulting, LLC

Norcal group website  

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