How do you streamline clinical documentation?

Regularly review and update templates to ensure they remain relevant. Template Optimization is needed to remove redundant fields and streamline templates to capture only essential information.

Patients aren’t like Google, Siri, or your friend Alexa- you can’t just ask them a question and they give you a straight answer; and let’s face it- sometimes we don’t even get a straight answer from our little AI friends. If AI is brought into clinics - to help collect real-time data, then the end user needs to be able to modify what was generated by the device to EHR. It would be great if my patient told me they were in for a check up and that’s all AI picked up… but what if the patient told me about their mom’s new breast cancer? Would that go into the patient’s record? Would AI have captured it was the patient’s mom & not the patient? These are the questions we must ask before we fall in love with all things AI in our healthcare world.

Yes to all of the above, however, standardized templates should be provided for the physician to be able to verbally modified nuances that either enhance each step or include unanticipated differences between the template and the actual diagnosis, procedure on top of the standard template.

Agreed, however, even if the appropriate dictation is made, the team should be identified for post submission confirmations or input when needed.

Discrete data is crucial in healthcare today to help create enough information to track and trend toward public health safety knowledge, in addition to tracking individual patient safety, quality, performance improvement, and financial reimbursement requirements that help keep the doors of the facility open. Every piece of data input as clinical documentation creates an output and it’s important we ensure those outputs are captured and understood. Those who have that “need to know” should be able to visualize the patient’s data or information in a timely, seamless manner. Therefore, it’s ideal to bring integrated healthcare system representatives together when creating, designing, considering, and building, clinical documentation entry.

True! Clinicians would love to document as close as possible to the point of care, but often times find a barrier in cumbersome technology or documentation requirements that are spread throughout the system. This is where end-user usability becomes a key factor for clinicians. Having products, systems, and tools that consider and ensure end-user usability is functional, simple, reasonable, prompt, and manageable alongside workflows that involve patient interaction is a crucial component in documenting (and providing) care in a timely manner. We all want to live in a world where our providers make us feel seen and heard - given the ever increasing demands, it’s important they have the tools at their fingertips to know they are, too.

Redundancy (copy-paste and cloning) with EHRs has been a persistent and widely used method to inflate documentation for billing purposes. EHR features such as copy/paste should only be used judiciously. Auto-complete and auto-duplicate functionality of EHRs have damaged their clinical utility. EHR functions such as dropdown menus and copy/paste have created so much documentation bloat that clinical points and information are obscured and difficult to succinctly extract from medical records. In an attempt to maximize documentation quantity for reimbursement, administrative, or audit purposes, incorrect and misleading clinical information winds up in clinical records.

I agree there that copy-paste EHRs data to other documents often creates discrepancies in the real world. Same data does not need to be in multiple documents. A clutter-free, intuitive interface can reduce the likelihood of excessive or redundant data entry.

EHR's should be able to begin comparative analytics between cases for future projects like standardizing clinical and surgical protocols across services.

Every click has a cost- while its wonderful to have the power of the EHR to create detailed documentation, there is a risk that we create administrative burden and complexity in provider documentation. Every time we have a great add for some new data element we need to be rigorous about what we can subtract from documentation.