Excessive time spent charting is one the most common complaints among physicians today. While electronic medical records serve many functions to improve care and workflow, the abundance of data, pages, and clicks one goes through to complete a patient encounter can feel not only redundant but exhausting. An unfortunate byproduct is that the majority of physicians use only a small fraction of the EMR’s capabilities, writing their notes inefficiently. Taking the time to build a system for quick, complete, and simple note writing takes an investment of time upfront, but provides better documentation for ourselves, our patients, and other providers with less work in the future. Here are my top reasons to invest in creating an efficient note-writing system.
1. Quicker follow up visits
Efficient notes can be used to quickly see your patient’s active problems, management steps taken at the last visit, and objectives for the current appointment. Time spent sifting through the chart to derive why your patient is here is not only wasteful, but can reduce our patients’ confidence in our care.
2. Less chance of medical errors
Busy notes that include a multitude of now-resolved problems and outdated medications leave us liable to make mistakes. In an era of copy-forward, this occurs all too frequently, and while often benign, can lead to drastic errors of improper medication management, missed screening tests, or unnecessary care.
3. Better efficiency for our patient’s other providers
We’ve all been referred patients where the note from the referring provider is a disorganized mess. Spending many minutes searching the note for the reason for the referral and trying to understand the history is not only frustrating, but risks the patient not getting evaluated for the true concern of the referring physician. By contrast, clear and concise documentation lets consultants quickly and accurately know the clinical question asked of them, with sufficient context to make their assessment.
4. Easier for the patient to review
With the CARES act, patients have access to their medical records including our progress notes. While I personally believe progress notes are intended for the care team and should be written as such, many patients do review their notes to stay on top of their health. Writing efficient and clear notes not only saves you from patient calls and messages asking for amendments to fix errors, but improves their ability to understand their diagnoses and follow treatment plans accurately. (Augmenting this with printed patient instructions written in plain language is more important to patient compliance in my opinion - more on this in a future post).
5. Better medicolegal protection
Efficient notes clearly document a visit’s diagnoses, treatment, and medical reasoning behind management decisions. Needing to back up what you did in a trial without having documented at the time is far from ideal.
6. Easier coding
Being able to see the visit’s diagnoses and management steps taken in a clear and concise format leaves us with all the relevant coding features immediately visible. Guessing at the coding level leaves the risk of overcoding and discrepancies if audited. Safely coding at a low level leads to undercoding and therefore insufficient compensation for our time - which is certainly not efficient.
7. Less time spent writing notes
This may seem counterintuitive to some who write one to two sentence dated additions to their forwarded progress note. An efficient note may take more typing to complete, but with all of the relevant information concisely documented and organized, far less time is spent scouring the note for the details needed to write those one to two sentence updates.
Stay tuned for future on posts on the specific components of efficient notes and tips on building your own efficient note writing system.