Compliance | Reducing Documentation Time
A case of writer’s cramp
Is there a way for Shannon to spend less time on documentation and more time with her patients?
Shannon sat at her desk shaking out her hand, which had cramped up after 10 minutes of concentrated writing. She knew how important it was to provide accurate documentation of patient visits but capturing every detail in writing, then making Teresa type it into the computer, was eating up valuable time for both of them. Plus, Teresa was forever complaining about her handwriting, which she admitted was difficult to read.
There was a knock on Shannon’s office door. “Come in!” she called.
Teresa entered with a smile. “Hello, Shannon, I was wondering if you had a moment,” she asked.
“Of course, Teresa, what’s on your mind?” Shannon asked.
“I’ve been working on entering your patient notes from last week and it’s taking me a long time,” she explained. “I know you try to be thorough but there are times when I need to extrapolate certain tidbits of information based on what I know about the patients.”
“Well, we’re all taught when we go into medicine that if we don’t write it down, it didn’t happen,” said Shannon. “I do try to capture every detail I can.”
“And I do appreciate your efforts,” said Teresa. “But I’m not just dealing with the SOAP notes, I need to include images, forms such as Medicare, intake and verification of benefits lengthy tests and more.”
“How much time would you say this is taking you in any given week?” asked Shannon.
“I haven’t tracked my time but it takes hours,” said Teresa. “Not just in typing and attaching related documents, but also in touching base with you when I have questions that I can’t figure out from your notes or past patient records. That takes time away from your day and your patients as well.”
“It used to be so much simpler,” mused Shannon. “When I opened this practice, I could scribble myself some notes, stuff them in the patients’ paper files and forget about them until the next patient visit. I was able to spend so much more time with my patients!”
“It’s not just about spending time with the patients,” said Teresa. “Our goal is to help patients get better, and to feel so much better that they feel compelled to bring family and friends who may be suffering to see you as well.”
“That’s true we need happy, referring patients to make the practice grow,” agreed Shannon. “I wish there was a way to keep accurate, compliant notes in less time.”
“You mean besides taking that handwriting course I’m always nagging you about?” teased Teresa.
Is there a way to reduce the investment of time in documentation so that Shannon can focus on her practice and her patients?
Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.
Documentation is a big challenge to physical therapists. It takes time away from helping patients, but it has to be done well to remain compliant. Like other aspects of running a practice, it’s a juggling act of balancing time. But before you can manage resources, you have to measure them.
As a coach at Vericle Inc., I hear providers tell me their first priority is helping patients and wanting to increase the time they have with patients, but now they have to document everything in great details in order to stay compliant and/or to get paid which can be very time consuming. Vericle is a electronic system that helps a practice with workflow and accountability, always striving to improve features to streamline process for practices, the documentation platform continues to be improved upon to assist providers to minimize their documentation time allowing provider to spend more time with patients.
When I talk with my providers the two items I hear about the most are wanting to be able to spend more time with patients and fast, complainant documentation. These 2 items really go hand in hand the less time you can spend documenting the more time you can spend with patients. At Vericle we are constantly updating our documentation to stay complainant and to make documenting more efficient.
Shannon can spend more time treating patients and providing higher quality care by investing in a software that is easy to use, intuitive, saves time and is more compliant. I work with many providers who have invested this time and are reaping the rewards of being able to have more face time with the patients.
Shannon and Theresa have not tracked their documentation time, so they do
not realize how much time they are losing. If Shannon spends 5 minutes
writing and Theresa spends 5 minutes typing it, they are losing 10 minutes
a patient. If they see 200 patients a week, they are losing a combined
total of over 33 hours a week. With their current process, how can Shannon be sure each visit is documented? Implementing a full practice
management solution that includes an electronic medical record would
not only reduce the documentation time, but include
automation/accountability to ensure each visit is documented.