Six EHR documentation tips to save you time

After a long day in clinic, the last thing you need is a stack of unfinished EHR documentation waiting for you to finish up at home. To reduce your work after clinic, consider ways to make the documentation process more efficient so that you can complete most (if not all) of this work during the visit. Here are six tips to get started.

1. Set up your computer in the exam room in such a way that you can alternate between looking at the screen and looking at the patient with only a small shift in your gaze. Never have your back to the patient.

2. Learn how to use templates and smart phrases to reduce the amount of typing needed, particularly for notes and phrases you use repeatedly.

3. Do not type long paragraphs. Instead, type short phrases. For example, ”Frontal HAs for 10 yrs; worse for 2 mos; now QOD; 9/10 severity; has visual aura, photophobia, phonophobia. Anterior left knee pain for 2 mos; worse for 2 wks; worse running downhill.”

4. Use patient questionnaires, preferably electronic, to collect data for the review of systems or other common scenarios (PHQ-9, sleep apnea, adult attention deficit hyperactivity disorder screenings, etc.). This way, instead of you or your staff asking patients every question, your patients can gather their own data for you.

5. If you use dictating software, take the time to train it so that it will be much more accurate.

6. Consider using a scribe or team documentation, which frees you up to focus less on documentation and more on patient care.

Read the full FPM article: “Ten EHR Strategies for Efficient Documentation.”