Six documentation tasks your team could be doing

In 2015, the A.F. Williams Family Medicine Center piloted a team-based care model, in which it increased the ratio of medical assistants (MAs) to providers from less than 1:1 to 2.5:1 and expanded the role of MAs to include the following tasks during a patient visit:

1. Elicit a comprehensive patient agenda,

2. Collect or update elements of the patient's past medical, surgical, social, and family history in the electronic health record,

3. Conduct detailed medication reconciliation, including removing expired prescriptions and marking medications due for renewal as “pending,”

4. Use templates to document a basic complaint-based history of the present illness (HPI) and review of systems to begin the visit documentation for the provider (the provider later confirms key elements of the HPI with the patient to meet billing requirements),

5. Use protocols to initiate certain clinical tasks, including rapid strep, urinalysis, urine HCG, A1C, and adult immunizations when indicated, prior to the provider portion of the visit,

6. Review preventive care gaps (lipid and diabetes screening, mammograms, colon cancer screening, hepatitis C screening, immunizations, etc.), and either order the services based on protocols or mark them as pending for the provider to review.

The MA then stays with the provider in the exam room to provide additional documentation support.

After implementing team documentation, the group saw an increase in visit volume, improvements in patient access, improvements in provider experience, continued “excellent” scores for staff and patient satisfaction, and improvements in measurable clinical quality.

Adapted from “A Team-Based Care Model That Improves Job Satisfaction.”