How to Improve Documentation In Healthcare

Healthcare workers usually choose their profession to help heal others. What they didn’t necessarily sign on for is completing and documenting the mountains of patient records now required each day themselves. 

However, we do know that proper documentation of healthcare records helps facilitate better patient care, reduces errors and keeps current and future providers informed about a patient’s condition. Isn’t there a better way to retain important information? We think so.

Over 50% of All EHR Users Said It Has a Negative Financial Impact on Their Practices

improve documentation in healthcare

Source: 2018 Medical Economics Survey

Studies suggest that medical practices with multiple physicians will spend over $160,000 to implement an electronic health records (EHR) or electronic medical records (EMR) system. Almost half of that total, roughly $85,000, goes to first-year maintenance costs.

Interestingly, over half of respondents in a Medical Economics survey responded that EHRs have a negative impact on practice finances. Over 70% of those same respondents indicate they would like their next EHR system to be more “user-friendly.”

When healthcare records are accurately inserted into a patient’s chart, it benefits both current and future providers, as well as the patient. Unfortunately, no person or process is perfect, and that includes providers and EHR or EMR platforms. Fortunately, there are consistent efforts devoted to documentation improvements designed to improve accuracy, patient diagnoses, and reimbursement. 

Why is documentation so important in healthcare?

improve documentation in healthcare to help curb doctor burnout

There are many reasons why accurately documenting a patient’s healthcare records is important. First and foremost, it allows for a continuum of information to flow smoothly from one provider or specialty to another. 

Medical transcriptions contain data and critical information regarding the patient’s past and present condition, as well as treatment protocols. In short, accurate healthcare documentation should provide an accurate description of the patient’s medical story. 

Healthcare documentation improvement is also important because it allows for accurate and timely reimbursement. Any healthcare institution or clinic will cite the importance of being paid on time. A profession known as clinical documentation integrity (CDI) is charged with ensuring healthcare records are documented accurately and thoroughly. 

The history of healthcare documentation

Historians have found evidence that ancient Egyptian’s kept information on patient’s medical conditions. Interestingly, only since the early 1900s have medical records been consistently maintained. Before EHRs were introduced, individual providers placed handwritten notes in each patient’s medical file. 

Transferring this information between a physician’s offices or departments within a medical institution was challenging, if not impractical. Plus, it created mounds of paperwork, as files had to be copied when forwarded to other providers. 

Until the mid 1960s, medical records were manually recorded on paper and filed with a patient’s chart. Lockheed developed the first electronic system for keeping medical records and the Department of Veterans Affairs began keeping electronic records of patients in the 1970s. 

Over the next 30 years, more practices and institutions began using some form of electronic record keeping. EHRs became more prevalent in the 1990s when local area networks and internet services became more accessible and faster. However, the widespread use of EHRs was impeded by redundant systems, high costs, data entry errors, and little incentive for physicians to implement its use.

In 1996 Congress passed the Health Insurance Portability and Accountability Act (HIPAA) which addressed medical privacy issues. This increased the use of EHRs in order to comply with new healthcare regulations.

In 2004, the federal government created an office to oversee the conversion of manual medical records to EHR.  According to government agencies, physicians’ use of EHRs in its early days increased from 18% in 2001, to 57% in 2011. Today that number is around 70%, although 98% of hospitals use some form of an EHR.

What is effective healthcare documentation?

improve documentation in healthcare with better communication

Documenting accurate information about a patient is critical in order to provide optimal care. When poor record-keeping occurs, it often leads to both internal and external reports being incorrect. More importantly, patient care suffers. 

Accurate healthcare documentation records all details of patient monitoring and treatment. If done properly and in a timely manner, the patient will benefit. Plus, effective documentation will protect the provider from unnecessary legal problems. Most importantly, it ensures professionalism and is proof the provider believes accurate record-keeping is important.

Some key factors of effective healthcare documentation include:

  • Provide factual, consistent, and accurate input
  • Update the information after any recordable event
  • Make sure all information is current
  • Confirm that all entries are legible and signed
  • Avoid meaningless jargon, phrases or abbreviations that aren’t commonly understood

What causes poor healthcare documentation?

The answer to this question depends on who you ask. For physicians and nurses, anything that impedes recording patient information or treatment may result in poor documentation. 

Poor record-keeping involves the following:

  • Inaccurate entries
  • No clarity to the entry
  • Spelling mistakes
  • Missing Information
  • Copying and Pasting 
  • Failure to correct inaccurate information in a timely fashion
  • Using incompetent service providers who don’t understand medical jargon

What is Clinical Documentation Improvement?

Clinical documentation improvement (CDI) assists practitioners with capturing accurate EHRs. It also helps facilitate that all members of the healthcare team receive pertinent information about any patient. CDI (aka clinical documentation integrity) also comes with many benefits.

CDI is a relatively new specialty within healthcare administration that focuses on making certain the process of record-keeping, especially electronic health and medical records are accurate and of high quality. The process is utilized extensively in hospitals. However, an increasing number of private practices are training employees in this area.

Almost 90% of hospitals with more than 150 beds and outsourced clinical documentation functions saw gains of at least $1.5 million in healthcare revenue and claims reimbursement following CDI implementation, a 2016 report from Black Book Market Research found.

A recurring problem with electronic health records is compliance. In 2016, the American Medical Association (AMA) found that for every hour clinicians spend with a patient, the clinician then spends two hours on EHR documentation. Providers spend 27% of their work time on direct patient interactions, and about 49% on EHR documentation.

Additionally, physicians spend an average of two hours working on EHR data entry outside of their office hours. This is why many physicians are experiencing burnout. 

Other ways to improve healthcare documentation is using workflow documentation tools, such as pre-structured data elements. The intent is to reduce the time spent charting and free up more opportunities to connect with patients and devote attention to their needs.

In the end, provider education is key and what CDI is all about. There is definitely a need for a higher level of specificity in the documentation process.

Recommendations to improve healthcare documentation

using technology better will improve documentation in healthcare

We understand that accurate healthcare documentation often feels like a chore. Keeping timely and complete records can be simple and straightforward. Here are some tips to help:

  • Keep in mind that whoever reviews the record doesn’t always have the depth of knowledge of the person who made the entry
  • Good EHRs should properly document the status and condition of the patient
  • Make sure other providers know the patient’s limitations
  • Confirm the EHR tells an objective story of the patient
  • Document why and how a patient’s condition has changed
  • Are all entries understandable and coded properly
  • All documentation should include patient and family directions
  • Care entries should reflect the level of care the patient is receiving
  • Make certain all entries comply with regulatory, licensure and quality standards
  • If a transcription service is used, make sure they are U.S. based and understand the context and can properly transcribe American medical jargon

Over 70% of the survey respondents indicate they would like their next EHR system to be more “user-friendly.”

Another way to improve documentation in healthcare, in general, is by retaining a qualified, U.S.-based, medical transcription service, that can interface with your EHR making the documentation requirements of the medical providers 1/10 of what they are required to do now.

Over the past few years, some providers have tried to save money by mandating that physicians and other practitioners transcribe their own healthcare records. While it’s simple to think performing tasks in-house will save money and time, often the opposite is true. Or, they retain unqualified, foreign-based companies who advertise low rates. Unfortunately, most of the time these types of transcription services deliver low-quality transcriptions. 

All of the medical transcriptionists we hire and train are specialized in specific areas, such as pathology, cardiology, or orthopedics.  Our company is also HIPAA compliant and accustomed to handling complex medical transcriptions and EHR interfaces.