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A Guide On How to Improve Medical Documentation

Governments give priority to quality healthcare delivery by training medical practitioners and providing the necessary healthcare infrastructure. As a private medical practitioner, it is imperative that you have an efficient system of documenting the medical records. In many health centers, poor documentation is a big issue that should be addressed. Today, most of the doctors spend a significant amount of their working hours entering data into the EHR. Medical documentation is a big challenge that can affect your practice and this can be made easier using certain excellent tips. The most common way to improve data entry efficiency is the use of EHR software. Keep reading the article herein to learn how to improve medical documentation.

Delegation can help you ease your medical practice schedule. No doubt, data entry takes too much time of a doctor, and that explains why reassigning is a good idea. The decision to hire an individual to help with the task should be made after examining the capability to transcribe data and enter it into the EHR. In most cases, medical doctors opt for a medical scribe, but this can be costly. The other means to improve efficiency in medical documentation is using dictation software. However, you will have to create some time to summarize and edit the notes transcribed by the software.

Next, you should consider optimizing billing, which is a common EHR shortcut. Most medical practitioners lose revenue through under coding, and the risk is high if you check the medical records between the patient visits. In the event of over coding, you might end up paying a lot of penalties to the insurance companies. The common causes of under code include lack of full diagnostics, lack of procedural specificity, and missing information. By optimizing billing, you will be sure that no information will be left out. Multitasking can compromise the efficiency of medical documentation, and this can be avoided by creating a time schedule.

Finally, follow the 2-minute rule. Once you reassign some of the documentation tasks that consume your time and adopt a time schedule, you should consider adopting the 2-minute rule. 2 minute rule simply means that you should handle all the task that takes less than 2 minutes now. Also, you should consider breaking down the large daunting tasks into small ones.

Using the above-discussed ideas and tips, you will be sure of an efficient medical documentation process.

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