12 Tips To Improve EHR Clinical Documentation
By Katie Wike, contributing writer
To improve your EHR clinical documentation, just follow the American College of Physicians’ recently-released guidelines.
How can providers improve documentation and, as a result, enhance patient care? The American College of Physicians (ACP) writes that, to meet this goal, it’s necessary to use the best clinical documentation possible - and in this era, that means EHRs.
According to EHR Intelligence, although EHRs have increased documentation and made it easier for doctors to defend against malpractice suits, the same wealth of information can sometimes hinder understanding a patient’s records during their actual care.
“The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up,” explains the report. “Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.”
The report suggests, according to iHealth Beat, seven policy changes to improve EHR clinical documentation as well as five policy changes related to EHR design. For physicians, the ACP suggests laying out defined professional standards, as well as better EHR documentation. This means including a detailed version of the patient’s story and also any previously documented information.
“Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care,” the report concludes. “Cooperation is needed among industry health care providers, health care systems, government, and insurers to continue to improve the documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member.”