I’ve noticed a trend among optometrists to take a long time to review and edit patient records within their electronic health record (EHR) system. This is certainly not universal, but I see it often enough that it is worth bringing up in this column.
Of course, clinical records are the domain of each doctor and no one should tell you how complete they should be. If you are audited by an insurance company or the federal government, the records must be able to defend the billing and coding that you submitted and they must accurately reflect the care you delivered. And if patients or other doctors ask for a copy of the records, it is very convenient to just print them, send them or produce an auto-report letter from the content of the record. Hopefully, we all agree on that, but I see and hear about doctors who go way beyond normal in their quest for perfect records. I know doctors who spend hours per day reviewing charts after the patient visits! I know doctors who access their patient records from home and work on them at night. In the name of efficiency and profitability, I can’t help but challenge this and think there has to be a better way.
Usually, my tip articles try to offer a solution to a problem, but in this case, all I can really do is make you aware of a possible problem; how you fix it will depend on you. In fact, you may review records meticulously and not think there is a problem at all. It is all really up to you, but if you think you spend too much time on record-keeping, I’ll provide the encouragement to fix it and also a few ideas on how to do so.
Scribes are not perfect
I am a big advocate of using scribes to record the exam data during the patient visit. This is high level delegation that takes the EHR burden off the doctor and lets him or her concentrate on the patient in the chair. It is important for the doctor to review each chart before finalizing the record because scribes and technicians can get things wrong (so can doctors). They could leave some results out or record some data incorrectly. They may not get the assessment and plan just right. They could misspell some words in the history.
The best time to review a chart is soon after the visit when memory can still serve. There may be some back-up paper forms (to be shredded later) that can be useful to check numerical data. I would estimate that the average review and edit would take far less than five minutes per patient. Generally, there is enough time between patients to complete this during the same day the patient was seen.
Need to do interpretation and report
Let’s acknowledge that a separate interpretation and report is required for any diagnostic medical procedure that is performed. That should be completed during the record review but it does not need to be very time consuming.
Abbreviations are OK
I believe medical abbreviations and acronyms are perfectly acceptable in the record and scribes should be encouraged to use them. I recommend that a clinical reference manual be maintained which includes a complete list of all abbreviations and what they mean. This is helpful for staff members and in case of an insurance audit.
A considerable amount of time can be consumed in writing narratives at the end of the record about medical advice that was given to the patient during the visit. There is no need to reinvent and type this for each patient. Consider developing a master document of macros, within the EHR software or in a separate Word document, which contains the usual verbiage you provide for various eye conditions. Depending on the software, there might be a keyboard shortcut, a dropdown list or simply copy and paste a paragraph of text into the EHR.
Reference clinical handouts
Instead of giving a patient a lot of verbal instructions, which they probably do not understand or remember, and then entering a summary into the record, why not develop a series of clinical handouts on common eye care topics. These can be prewritten in your own words with the advice you actually give. You can tell the patient briefly what he needs to know and give him the appropriate handout to take home. Document which handout was given in the record instead of writing it out. You could have one on blepharitis, flashes and floaters, dilation advice, instilling eye drops, hot compresses, etc. Place a copy of each handout in your clinical reference manual.
Saving time on record keeping is worth a great deal of effort because once your methods are improved, you save time every day for years to come. Track the time you are spending on your records and invent ways to make it more efficient.