HCPro, a healthcare education company, shares that incomplete patient clinical records can impact doctor and patient alike. For the practitioner, failing to put all of a patient’s personal and exam-based information can result in decreased rates of reimbursement, uncollected claims, and lower levels of patient care. In extreme cases, you could lose your license. For the patient, missing health information can easily translate into sub-par care and possibly even misdiagnosis and treatment.
That’s why it’s so important to have complete and accurate records of your patients and the services you provide them. This reduces the risks for both of you while increasing the quality of your care. One way to achieve these goals is by using electronic health record (EHR) technology – a tool that can dramatically improve the quality and accuracy of your health records.
Documenting While the Patient Is Present
Think about the frustrating moment when you go into a room to get something only to forget what it was you were after. This happens because we can only commit five to nine things to our short term memory at a time…and they’ll likely only stay for 30 seconds max.
Now think about all the things rolling around in your mind when seeing a patient. You’re going over their history, asking them about their current health, maybe even chatting about their family or the weather. So what’s the likelihood that you’re going to remember all of their medical information for charting after they leave? It doesn’t look good.
When you use an EHR system, it enables you to easily chart your notes during the patient visit. This means greater levels of accuracy because you’re writing down what they’re telling you and what you’re finding at the moment, limiting your reliance on memory. It doesn’t take much time either compared to paper charting. With EHR documenting, it should typically take between 15 and 20 seconds for daily notes and as little as 1 minute for exams – all while the patient is with you in the room.
Accurately capturing a patient’s issues or chief complaints is critical to being able to diagnose and resolve them. What better way to do that than having them write it down in their own words? The same is true when it comes to their health history, lifestyle behaviors, and all other factors that can affect their quality of life. Again, this is where EHR’s come in.
For example, using waiting room kiosks can allow patients to record their own complaints, medical histories, health questionnaires or other intake forms. Aside from the obvious time-saving capabilities, kiosks are a powerful tool that allows patients to share their health information in their own words making documentation and communication much more accurate.
EHR’s Built on Graphics User Interface (GUI)
To best understand how graphics enhance EHR accuracy, think back to the way health practitioners used different colored folders or labels to organize their patient records. Just one look and you could instantly tell what type of file it was. This saved you a tremendous amount of time flipping through each one individually while minimizing the risk that you’d confuse one type of patient with another.
An EHR, that uses a graphic user interface will offer the same type of visual cues by using images or pictures. Whether they’re images of tests, exam findings, or areas of grouped diagnoses, GUI functions help you find and record information faster with fewer steps.
There are other benefits of graphics as well. For instance, your brain processes picture more efficiently than words, images help you better interpret the data you’re viewing, and they also make it easier to put the information together in a way that gives a complete picture. There’s really no downside to graphics!
Improving EHR Efficiency With Macros
EHR technology also provides the ability to link multiple steps in documentation into fewer steps. For example, let’s say you use two separate programs: one for EHR the other billing. To process claims, your staff needs to enter the treatments and diagnosis information from your notes into the billing software. These extra steps are redundant and can be eliminated when using EHR system that automatically imports treatments and diagnoses into the billing system. The function that combines these two steps into one called a macro.
Other examples of a macro would be listing specific treatments in notes based on exam findings. For example, as chiropractors, we typically adjust subluxated areas. So instead of selecting the adjustment treatment, the program would automatically do this when you selected specific subluxated areas. Again, the same could be true if you typically massage spastic muscles. When you record muscle spasms massage treatment would appear in your notes at the same time.
Macros can be applied to any area of an EHR system but the above mentioned are most common. Exercising the use of these functions is not only a powerful way of improving efficiency but make your documentation much more consistent. Just be sure whatever macros you use don’t cause notes to appear salted. This refers to the SALT acronym which stands for Same As Last Treatment. Insurance companies are very keen on this and may deem your care as medically unnecessary.
Using an EHR system at your chiropractic practice means a greater level of health record accuracy. That’s clearly a benefit for everyone involved.