Completing visit notes in a timely manner can be a challenge thanks to complex documentation guidelines and cumbersome electronic health record (EHR) systems. To get through your routine documentation more efficiently and reduce work after clinic, try the following tips:
1. Leverage the skills of your team members. Don’t document everything yourself. Empower your medical assistant (MA) or nurse to document the patient’s concerns, review medications, and verify or document allergies. You’ll still need to review the information for accuracy, but you don’t need to gather and enter all the information yourself.
2. Get done what you can in the exam room. You may not be able to complete all of your charting while in the exam room, but try to do parts of it. For example, as you discuss the treatment plan, make notes in the EHR as you go, summarizing aloud to engage the patient and ensure understanding.
3. Know the documentation guidelines. You don’t need to document a comprehensive review of systems or a comprehensive exam to meet the requirements for a 99213, for example. Document what’s medically necessary and complete for today's visit, and no more. (See the FPM Documentation Guidelines topic collection.) And if your MA has already entered the chief complaint or history information, you do not need to re-enter it yourself, per recent guidance.
4. Use your basic EHR functions. If you find yourself typing the same information over and over again, consider making an EHR template that will save you time down the road. To find out what other automated tasks are available in your EHR, talk to your colleagues and share tips.
Read the full FPM article: “Getting Your Notes Done on Time.”
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