Techniques to reduce chart review burden
Technology has eased chart review, but it still takes time. Use these strategies to beat the clock.
- Techniques on this page
- EHR configuration
- Next visit prep
Physicians have seen a revolution in health information technology, with enormous advances in electronic health record (EHR) systems. But even users who have mastered this tool report that it demands more and more time. Today, physicians interacting with EHRs spend more time on chart review than they do on clinical documentation. How did this happen, and how can you regain control of your time?
Technique 1: Configure EHR problem-oriented summary
Many EHRs have dashboards, templates and reporting tools that can help automate chart review by pulling information into patient and problem-oriented summaries. Reviewing these summaries is much quicker and more efficient than having to click all over the EHR to find the needed data.
Physicians can tailor such summaries to include a number of things, as the examples below demonstrate.
- Patient’s name
- Demographics
- Allergies
- Active problem list
- Current medications
- Vital signs
- Laboratory results
- Diagnostic test results
- Imaging test results
- Consultation results
- ER visits since last visit note
- Hospitalizations since last visit discharge summary
- Current coded diagnosis
- Current medications
- Recent laboratory results
- Procedures relevant to the specified disease
- Relevant medications
- Laboratory results
- Procedures
- Past encounters
- Clinical events
- Relevant medications
- Laboratory results
- Procedures
- Past encounters
- Clinical events
Technique 2: Start next visit prep at end of current visit
At the end of your current visit, you have the patient’s entire case before you. Take advantage of that; document now what you’ll need at the next appointment, including preventive services, orders and next steps in the management of any chronic disease. When it's time for that next visit, this summary will help reload the patient’s case. Additionally, this documentation can help with recording your medical decision-making for billing purposes.