Compliance | Reducing Documentation Time
A case of writer’s cramp
Is there a way for Dr. Ben to spend less time on documentation and more time with his patients?
Ben sat at his desk shaking out his hand, which had cramped up after 10 minutes of concentrated writing. He knew how important it was to provide accurate documentation of patient visits but capturing every detail in writing, then making Luisa type it into the computer, was eating up valuable time for both of them. Plus, Luisa was forever complaining about his handwriting, which he admitted was difficult to read.
There was a knock on his office door. “Come in!” he called.
Luisa entered with a smile. “Hello, Dr. Ben, I was wondering if you had a moment,” she asked.
“Of course, Luisa, what’s on your mind?” Ben asked.
“I’ve been working on entering your patient notes from last week and it’s taking me a long time,” she explained. “I know you try to be thorough but there are times when I need to extrapolate certain tidbits of information based on what I know about the patients.”
“Well, we’re all taught when we go into medicine that if we don’t write it down, it didn’t happen,” said Ben. “I do try to capture every detail I can.”
“And I do appreciate your efforts,” said Luisa. “But I’m not just dealing with the SOAP notes – I need to include images, forms – such as Medicare, intake and verification of benefits – lengthy tests and more.”
“How much time would you say this is taking you in any given week?” asked Ben.
“I haven’t tracked my time but it takes hours,” said Luisa. “Not just in typing and attaching related documents, but also in touching base with you when I have questions that I can’t figure out from your notes or past patient records. That takes time away from your day – and your patients – as well.”
“It used to be so much simpler,” mused Ben. “When I opened this practice, I could scribble myself some notes, stuff them in the patients’ paper files and forget about them until the next patient visit. I was able to spend so much more time with my patients!”
“It’s not just about spending time with the patients,” said Luisa. “Our goal is to help patients get better, and to feel so much better that they feel compelled to bring family and friends who may be suffering to see you as well.”
“That’s true – we need happy, referring patients to make the practice grow,” agreed Ben. “I wish there was a way to keep accurate, compliant notes in less time.”
“You mean besides taking that handwriting course I’m always nagging you about?” teased Luisa.
Is there a way to reduce the investment of time in documentation so that Dr. Ben can focus on his practice and his patients?
Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.