Techniques to improve physician documentation
Whether at the point of care or after hours, these strategies can help you reclaim valuable time.
- Techniques on this page
- Redesign your visit
- Optimize your EHR
- Adopt E/M coding guidelines
Why reducing documentation burden matters
Reducing administrative burden is at the heart of improving physician well-being, and the numbers bear it out: in a Medscape 2024 survey, more than half of family physicians reported feeling burned out, and too much administrative work was cited as the top reason. Burnout can lead to anxiety and depression, affecting professional and personal relationships, and the quality of care you can provide your patients.
The following techniques don’t require any large purchases or organizational approval. Instead, they focus on helping you optimize your current processes and workflows in three main areas.
Point-of-care documentation strategies
As a practicing family physician, you’ve developed your own style of conducting and documenting patient visits. You may prefer to complete your notes while you’re still in the exam room or at a later time, such as between visits, at lunch, after work, or at home. Your style determines the time and effort this task requires and, in turn, your level of burden.
Here’s how some of your colleagues have redesigned the patient visit experience and reduced their documentation burden.
Redesign your patient visits
Position your computer where you can alternate between looking at the screen and looking at the patient with only a small shift in your gaze.
Make sure you’re always facing the patient so you can pick up important nonverbal communication cues and behaviors.
Use a laptop computer, or a monitor that swivels or is on wheels, to make it easier to share information with the patient.
When conducting a telehealth visit, have one screen that displays the patient and a larger screen that displays the EHR for documentation. Make sure the screens are positioned to minimize any shift in gaze from one to the other.
Based on previous visits, anticipate what tests or imaging will be needed and pre-order them.
Have a medical assistant (MA) review the patient’s record to see what needs the patient may have and what prep work can be done.
Have a care team member call to clarify the patient’s agenda, anticipate needs and complete tasks usually performed during rooming (e.g., reviewing medications, screening for depression or falls).
Have the patient complete a pre-visit questionnaire, either on paper in the reception area or via a patient portal, that can cover a range of topics.
Have the MA ensure the patient has completed the appropriate visit questionnaire that maps to your visit template.
With the right EHR functionality in place (see next section), you can review and accept the patient’s answers in the note template with just a few clicks.
EHR documentation standards and best practices
Using the documentation tools built into your EHR will reduce the amount of time and number of clicks needed to document each visit. It can make your EHR feel more user-friendly and, at the very least, you’ll know you’re using it to its fullest extent.
Optimize your EHR
Master all the tools at your disposal, including templates, macros, patient questionnaires, pick lists, etc.
Take advantage of additional training materials and opportunities.
Ask your IT staff, EHR support team, or a superuser for help.
Although time spent by ancillary staff on documentation does not count toward total time used to select the level of E/M (office visit evaluation and management) service, smartly-designed templates and pick lists enable clinical staff to fully capture patient history and intake information, allowing you to review and accept the information with just a few clicks. Steps you can take:
Ensure your visit template pulls health maintenance needs, depression screening and social history into the note from data found elsewhere in the EHR.
Develop a comprehensive pick list of chief complaints that staff can select during the rooming process for patient questionnaires.
Identify or create a set of macros that you know well and that works for your practice. You can obtain useful sets from your EHR company or organization, or you can enlist the help of a superuser.
When using templates, ensure your documentation reflects what occurred during the specific encounter. For example, patient instructions should be personalized according to the patient’s clinical profile.
Continually improve your templates and macros. If you find yourself repeatedly entering the same information, take the time to save it as a template or macro. If you find you are constantly deleting or modifying your templates, change them permanently.
Remove template reminders once you no longer need them.
Learn how to quickly turn a part of a note into a template.
Learn how to save a common phrase into a macro.
Patient questionnaires can help you document your visits. These questionnaires can often be linked directly to visit templates. Steps you can take:
Create a standard visit note template driven by patient questionnaires. Document who entered the information in the EHR and who reviewed it.
Create a set of standard patient questionnaires to cover the most frequent complaints.
Ask your MA or front desk to have patients complete the relevant questionnaire online before their visit. Their answers will auto-populate the HPI section of the note, reducing the team’s documentation during the visit.
For patients unable to complete questionnaires ahead of time, your staff may pull up questionnaires in the exam room so patients can answer them while waiting for their clinician.
You don’t need to repeatedly document recurring visit elements in the chart. Elements such as medical history, medications and allergies can be updated in the chart lists and referenced in your visit templates. Steps you can take:
Create note templates that contain hyperlinks to medical history, surgical history, medications and allergies.
With one click, without leaving the chart note, the clinician can view these elements of the patient record and edit them or bring forward updated information, as needed.
Reviewing these elements is documented “behind the scenes,” so this action counts toward medical decision-making (MDM) without requiring that the elements be included in the current visit note.
The updated E/M coding and documentation guidelines changed documentation requirements with the goal of reducing burden. The following steps can help you take full advantage of the changes.
Focus on telling the patient history story. Modify the review of systems (ROS), when used, to reflect problems addressed or managed during the encounter. A full ROS is no longer used to select the level of service but should be considered and documented based on the patient’s clinical presentation.
A problem is considered to be addressed or managed when it is evaluated or treated during the encounter by the physician or other qualified health professional (QHP). Make sure your documentation reflects this.
Restructure your physical exam section by eliminating exam bullet points. They are no longer required for “scoring” purposes.
Ensure templates automatically list diagnoses (including their status) and associated orders in the assessment and plan so you can refer to them while documenting your MDM.
Most EHRs let you create a patient clinical summary or dashboard. Using this feature allows you to review chart data while still documenting.
Customize your patient summary or dashboard to include pertinent patient data for chart review.
Modify your display settings to present the data at a glance without having to open the chart.
Templates for common visit types include:
Physical exams
Routine office visits
Procedures (minor office)
Patient instructions
Specific parts of exams (e.g. knee exams)
List of numeric objective data (e.g. most recent BP readings, weights, A1Cs)
Clinical and behavioral documentation examples
In response to advocacy from the AAFP and other medical specialty societies, the Current Procedural Terminology (CPT) editorial panel revised the office visit E/M documentation and coding guidelines in January 2021. As part of the continued effort to simplify documentation requirements and reduce burden, the CPT editorial panel revised the E/M documentation guidelines for several other E/M services in January 2023. The 2023 changes were largely an expanded application of the 2021 office visit E/M guideline changes. Both Medicare and private payers have adopted the updated guidelines.
Update your E/M coding
History and physical exam elements have been eliminated (when not appropriate) and are no longer components of E/M code level selection. The patient history and physical exam elements are no longer components of E/M code level selection. These elements may still be necessary for clinical practice, professional liability (i.e., malpractice) reasons, and quality measurement, however, and should still be documented as medically appropriate.
The MDM table has been revised to more appropriately reflect the cognitive work required for E/M services.
The definition of time for many E/M services is no longer restricted to time spent counseling the patient. Physicians can now use total time to select the level of service. Total time includes all physician or QHP time (both face-to-face and non-face-to-face) spent caring for the patient on the day of the encounter.
Total time may be used alone to select the appropriate code level for office visit E/M services (992029–9205, 99212–99215) and certain other E/M services. A key change in the updated guidelines is the definition of total time.
Time may be used to select the level of service regardless of whether counseling dominated the encounter. The revised definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes:
Preparing to see the patient (e.g., review of tests)
Obtaining and/or reviewing separately obtained history
Ordering medications, tests or procedures
Documenting clinical information in the EHR or other records
Communicating with the patient, family, and/or caregiver(s)
Time not counted toward total time includes:
Activities normally performed by other clinical staff (e.g., your MA collecting a patient’s history)
Time spent on a date other than the date of service
Time spent on services that are separately reportable (e.g., interpretation of results, tobacco cessation counseling)
You should document the specific total time spent (not the range) on the date of the encounter. For more information on selecting the level of service using total time, visit the Coding for Evaluation and Management Services webpage.
MDM is a measure of complexity representing all the cognitive work put into diagnosis and assessment of a patient’s condition, including treatment options considered but not selected.
To qualify for a level of MDM, two of the three MDM elements for that level must be met or exceeded. The three elements are:
Number and complexity of problems addressed at the encounter
Amount and/or complexity of data to be reviewed and analyzed
Risk of complications and/or morbidity or mortality of patient management
View the full MDM table here.
By adjusting your documentation style, templates and reminders, you can leverage the positive aspects of the guideline changes. For example:
Minimize pulling data into your note that you can see elsewhere in the EHR.
Remove reminders you no longer need from templates to reduce note bloat.
Ask only the pertinent questions for each condition you address during an encounter, especially with complicated patients.
Impact analysis
The AAFP surveyed members in 2022 about adoption and impact of the E/M 2021 coding changes. Five out of 10 respondents (51%) saw a reduction in their documentation burden.
They reported the following changes:
68% said it was easier to select code
73% reduced documentation time
58% used MDM
Only 12% used total time
30% used MDM and total time equally as often
The other 49% of respondents reported they had not seen reduced burden because they:
were still unclear on interpretation
were unable to capture total time
had trouble using the new codes due to workflow or their EHR
used an EHR that included outdated E/M codes
These findings call for more education on the new coding requirements and techniques for adopting and implementing them on specific EHRs.