Electronic Provider Documentation

Michael Rose

Timely, accurate, and complete documentation of patient care has never been more important. Today’s increased emphasis on electronic records through federal and state incentive programs makes electronic documentation more essential as a component of a complete electronic record, both to comply with requirements and to facilitate the clinical users’ experience. The increasing complexity of care, the need to coordinate multiple members of the care team, and the need to support billing and coding with adequate clinical documentation all point to the value of effective, electronic note-writing. The end goals are clinically richer notes, more efficient documentation, and more correct billings.

Providers such as physicians, nurse practitioners and physician assistants interact and communicate with patients and other healthcare professionals every day.  These interactions can be in the form of patient assessments or interventions, orders for patient care, medications and diagnostic tests, or other communications.  The vehicle to capture many of these interactions and communications is the provider note – such as progress note, history and physical (H&P) and procedure note.  Although Electronic Medical Records (EMRs) have been available for decades, provider notes continue to be the outlier.  At present, the majority of provider documentation is created as free-text narratives and generated in a handwritten or typed format or is dictated by the provider and then transcribed.

At HIMSS10, Bob Dolin, MD, chair of the Health Level Seven international healthcare data standards organization and principal of Semantically Yours, LLC relayed that “over a billion clinical notes are created by physicians in the U.S. each year, comprising around 60 percent of clinical information – the majority of physician-attested information – and are used as the primary source of information for reimbursement and proof of service” [Link].  While this story is a couple years old, the problem is even older – how to effectively document the clinical essence of that encounter,  in a format that is legible and available to all authorized caregivers in a near real-time fashion without restricting the storytelling and data collection with rigid templates or restrictive electronic tools.

I posit that a superior electronic provider documentation solution supports the 7 “C’s” of good documentation:

  • Comprehensiveness
  • Convenience
  • Coordination
  • Communication
  • Coding
  • Compliance
  • Clinical research

In my next post, I’ll go through these components in more detail.

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