Team documentation: who does what during the visit?

Team documentation can boost physician efficiency, but which tasks should you delegate and which tasks should you keep?

Authors Kevin Hopkins, MD, and Christine Sinsky, MD, both use a team-care model, in which physicians perform the functions that only they are qualified to do (e.g., physical examination, synthesis of data, and medical decision-making) and delegate the other tasks to well-trained clinical assistants — registered nurses, licensed practice nurses, or very capable and experienced medical assistants.

Here’s how the process commonly looks in a primary care practice:

Clinical assistant begins the visit. The clinical assistant handles much of the initial data gathering, including documenting the patient's complaints and gaining additional detail through questioning. Protocols and templates based on specific patient complaints and chronic conditions direct the clinical assistant's questioning, and standardized text is available for the assistant to drop into a note for certain complaints. The assistant also reviews and makes necessary updates to the patient's medical, surgical, social, and family histories; reviews approaching or overdue health maintenance topics and pending orders for tests or procedures; and reviews the patient's medication list and upcoming refills.

Physician joins the visit. The clinical assistant then steps out of the room and presents the case to the physician, who reviews the patient's chart. The two enter the exam room together, and the physician greets the patient for the first time. The assistant remains in the exam room during the visit, sitting at the computer and serving as a scribe for the physician. The physician checks with the patient regarding the accuracy and completeness of the information gathered by the assistant, asks more directed, specific questions of the patient, and performs the physical exam. The assistant documents and immediately enters into the record any additional data, including pertinent exam findings. The physician then formulates a diagnosis and care plan with the patient and the clinical assistant. The assistant records all diagnoses for the visit as well as any orders needing the physician's approval. If directed by the physician, the assistant may also maintain the problem list. The patient is given an opportunity to ask questions, to make sure he or she understands the results of the visit, and then the physician exits the exam room to review and file the orders for the encounter.

Assistant wraps up the visit. The clinical assistant remains with the patient to end the visit by reinforcing the physician's instructions, providing prescriptions and referral information, delivering patient education, answering questions, and arranging appropriate follow-up, such as scheduling future visits. This allows the physician to move on to the next patient with whom another clinical assistant has performed stage 1 of the office visit, and the process repeats.

Read the full FPM article: “Team-Based Care: Saving Time and Improving Efficiency.”