Techniques to Reduce Chart Review Burden
Physicians have seen a revolution in health information technology, with enormous advances in electronic health record (EHR) systems. But even users who have mastered this tool report that it demands more and more time. Today, physicians interacting with EHRs spend more time on chart review than they do on clinical documentation. How did this happen, and how can you regain control of your time?
EHR Configuration
Find the small tools within the larger one to help you automate chart review.
Prep for Next Visit
Your patient’s history is in front of you right now. Take advantage of that.
Many EHRs have dashboards, templates, and reporting tools that can help automate chart review by pulling information into patient and problem-oriented summaries. Reviewing these summaries is much quicker and more efficient than having to click all over the EHR to find the data needed. Physicians can tailor such summaries to include a number of things, as the below examples demonstrate.
General patient overview
- Patient’s name
- Demographics
- Allergies
- Active problem list
- Current medications
- Vital signs
- Laboratory results
- Diagnostic test results
- Imaging test results
- Consultation notes
- ER visits since last visit note
- Hospitalizations since last visit discharge summary
Snapshot of a specific problem
- Current coded diagnosis
- Current medications
- Recent laboratory results
- Procedures relevant to the specified disease
Longitudinal timeline of a specific problem
- Relevant medications
- Laboratory results
- Procedures
- Past encounters
- Clinical events
Care gaps
- Relevant medications
- Laboratory results
- Procedures
- Past encounters
- Clinical events
Take advantage of the fact that, at the end of your current visit, you have the patient’s entire case before you. Document now what you’ll need at the next appointment, including any preventive services, orders, and next steps in the management of any chronic disease. When it is time for that next visit, this summary will help reload the patient’s case. Additionally, this documentation can help with recording your medical decision-making for billing purposes.
FPM: Putting Pre-Visit Planning Into Practice
Pre-visit planning can help make your patient visits run more smoothly, giving you time to focus on what matters most to the patient and even a little time to spare to simply visit with the patient. Furthermore, you may be able to head home an hour earlier, feeling satisfied with the day and a job well done, knowing that your patients and staff feel the same.
