Posted and filed under Coding, Compliance.

The keystone of Clinical Documentation Improvement is that quality documentation often results in quality continuum of care, and while this is true, many physicians report that paying too much attention to documentation actually leads to poor patient care. This poses a dilemma for some providers; do they care for the chart or for the patient first? While it may seem as though patient care should eclipse all other responsibilities, a patient’s care plan can be completely dependent upon the information documented within their charts. The daunting task of maintaining medical records is no secret to the industry, with Electronic Health Records and Electronic Medical Records being introduced as a way to optimize the process – but the need for meticulous record keeping remains the same, even with automation.

With paper charts, providers must handwrite and transcribe all their notes. With electronic records, providers must ensure that their software systems are not facilitating templating or cloning. In either scenario, there is a need for time, dedication, and quality assurance. Because providers rely on their documentation for payment of services, it is already a priority to get the documentation done – but as the opportunities for fraud, waste, and abuse (intention or accidental) increase, so does the time spent documenting.

Advize recently spoke to a doctor from a small practice in the Northeast who confessed that he was spending so much time documenting visits and maintaining patient charts, that he felt he was barely able to care for the patients face-to-face. This was not the first nor the last account of providers expressing these types of concerns but it was refreshing to hear that providers are growing increasingly aware of the problems and are actively seeking solutions to balance out the continuum.

Documentation and patient care are not problems exclusive to the United States. Pusan National University Hospital (PNUH), a Korean hospital, has introduced a voice keyboard to their providers. The keyboard has speech recognition functionality that allows providers to use their voices when documenting hospital medical records. The tool was designed to allow doctors the ability to concentrate more on the patient in real-time and documentation after the exam or procedure. This is not a one-size-fits-all solution, but it is a tremendous step in the right direction.

Now that we have come far enough into the process to consider EHR-implementation rather ubiquitous, what needs to be done end the conflict between time spent documenting and time spent physically caring for patients?

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