I have never spoken to a nurse practitioner, physician assistant, physician, or other clinician who enjoys documentation. And it seems that since going to EMR’s, I hear even more grumbling about documentation than ever. Some people abhor templates, others don’t type well and get further behind. If you use voice recognition software, you are likely aware of it’s challenges. Then of course there are all the ever-changing rules of documentation to meet coding and clinical guidelines. Most feel overwhelmed by the weight of all the documentation.
So what’s the solution? There isn’t one…or at least there is not just one solution that fits every situation, every EMR system, and every style of documentation. However, let me share a few tips that just might make your life a bit easier.
1. First and foremost, if you have can, have a say-so in the EMR used in your place of work. That’s relatively easy if you own the practice. However, if you don’t, what can you do? See if you can be involved in the evaluation process. Test out each system if possible, Talk with other users before a decision. If possible, visit the office using the system to see how it works.
2. Learn the system! What I mean here is that many of us use software…but barely. We know enough to make it somewhat usable, but in many cases, we don’t know how to use it to it’s maximum capabilities, and likely we don’t know it’s shortcuts. Spending some time to really learn a program will almost always save you time, energy and frustration in the long run.
3. Make use of templates, voice recognition and macros that may be inherent in your system. You’ll want to make sure that any templates can be customized to your style of working.
4. Make use of staff in the documentation process if possible. Are you having to spend time documenting items that your MA can take care of? Are you having to “sign off” items that do not require a clinicians sign off?
5. Use text expanders or text replacement software. One that I’ve been using for years is called ShortKeys. It’s a small little program for the PC, that when activated, can do things like insert a full normal exam (or whatever you choose) into your note to be tweaked to that individual patient, all by typing just a few characters. For the Mac, TypeIt4Me will do the same thing. There are several other replacement programs for the Windows and MacOS, just do a search.
This last little item, and a short demonstration, left the visiting NP giddy with delight and possibilities to speed up her own documentation.
Whatever your documentation style is, it’s imperative, in this always changing, complex world we work in that we get it done and get it right. Finding a way to do it, a system that works for you and allows you to get home at the end of the day, is our challenge and our goal.
What documentation shortcuts have you found that works for you? Share them with your colleagues below.