Patient progress notes play an integral role in providing quality care and ensuring the administrative side of medical work is managed effectively. Attention to detail and clarity are essential when crafting a patient health record.
The note-taking process has evolved over the past decade, shifting to a paperless, mobile-first protocol. While the technological aspect is a change, it offers ample opportunity to optimize this vital process.
Here’s how to optimize your patient progress notes to provide better documentation without sacrificing the integrity of your care.
Benefits Of Optimized Progress Notes
Before diving into how to optimize progress notes, it’s important to understand why you should make this change. Improving your progress notes for accuracy and efficiency offers several benefits.
Improve Billing Performance
One of the most notable benefits of optimized progress notes is improved billing performance. Having clear, defined notes is essential for a hospitalist billing company, particularly in nuanced fields like psychiatry. Clear notes mean more accuracy in coding and efficiency in the billing process.
A study by Dr. Angela Mirabella, BA, of the Frank H. Netter MD School of Medicine at Quinnipiac University highlights a common theme among hospitalists: missed charges and billing gaps. The study proposed poor communication and understanding between administrators and internists. Furthermore, it identified improved workflows and systems as the solution. Patient progress notes play a significant role in those solutions.
Improved Clarity And Legibility
Physician handwriting is notoriously bad. There’s science behind this phenomenon. Experts surmise that the small muscles in physicians’ hands get overworked from copious amounts of note-taking, starting during university. Pair that with an overfilled schedule, and you’ve got a recipe for illegibility.
Optimized progress notes and electronic health records (EHR) overcome this barrier. Investing in the right tools ensures patient information is clear and legible, and leaves no room for interpretation.
The more optimized your progress note-taking, the more productive you’ll become. Implementing the right tools and behaviors can help save time and stress as a rounding physician.
Reduced Care Gaps
Poor documentation is one of the leading causes of medical malpractice, following delayed treatment and diagnosis. The quality of your notes could impact how well a nurse or referring physician cares for your patient after you’re gone. Prioritizing this process is essential to protect the health and wellness of those in your care as well as your livelihood.
With those benefits in mind, here are the top considerations for optimizing your progress notes.
Use A Progress Note Generator
Progress note generators are robust, AI-driven tools that produce clear, informative notes with minimal time and effort. These tools are compatible with EHR documentation and ideal for individual productivity and communications with broader teams.
For example, rounding physicians can take a smartphone or tablet with them as they move through a hospital to visit new admissions and existing patients. All relevant information can be brought up with the click of a button, without having to flip through charts. Similarly, attending interns and other care team members can access the same information in real time.
Progress note generators also simplify data collection with pre-populated terms and search keywords. It’s estimated that the right tool can save up to 73% of admin time per patient.
Using the speech-to-text function in your progress note app is also beneficial. This functionality helps reduce administrative time further by eliminating the need for dropdowns and pre-populated sentence selection.
However, this function isn’t appropriate in all settings.
Prioritizing patient privacy is essential when transcribing notes. This approach can also feel more intrusive to patients if you’re capturing notes at the point of care. Investing in a high-quality speech recognition program that’s matched with medical terminology is also essential for accuracy.
Create Bullet Summaries
Progress notes should be detailed with all pertinent information outlining the patient journey. However, you may not need every detail as your time with the patient progresses.
Creating a bulleted summary of pertinent information to take with you to your next appointment will help you optimize your notes and your efficiency. Set aside time at the end of each appointment to review your notes and determine what information you’ll need for the next visit. Summarize those offline or within your app for a quick reflection.
Note Duration And Time Metrics
Include details about the date, time, and duration of your visits when interacting with patients. This helps establish a timeline in the patient journey and simplifies the review process. Rather than scrolling back through notes, you can use the date as a keyword to search and jump back.
These elements are also a must if you amend or update past notes. Never delete your previous entries; always amend with the new date, time, and reasoning for the edit. Electronic progress notes store metadata about when content was added or deleted, making this integral for any potential lawsuits.
Create Pre-work Flows
Work with your team to establish a pre-work flow. Set expectations for what paperwork and information patients should provide before your visit and how the team should prepare it for you. The more streamlined the pre-work, the more time you have to invest in patient care and documentation.
Monitor Your Time
Set time limits for working on your notes. If you struggle to reach these goals, analyze and determine what factors are impeding your process. It could be a lack of preparation or the wrong tools. Similarly, it could be an issue of when you’re scheduling your charting time or using too many details or flowery language.
Reflect And Adapt
Reflect upon your note-taking processes and abilities often. Look for common themes to identify how you can improve and optimize your notes further.
For example, suppose you’re a psychiatrist traveling between rehab facilities. You notice that one facility isn’t getting the details they need, creating a gap in patient care. The other facilities aren’t having that experience. What factors contribute to success at other institutions and how can you carry those flows to improve your note-taking at this one?
There’s always room for improvement in charting and progress note-capturing as a hospitalist. Keep these key considerations in mind to optimize your notes and improve the quality of your care.