|VIDEO| Tips for Faster Documentation

One of the most frequent questions I receive from busy clinicians is; “How can I get my documentation done faster and finish up my day faster?”

There is not one answer to this question, but here are some ideas to increase your documentation speed and get home a bit earlier using applications that fit your individual needs:

EHR/EMR’s speeds the process via templates, checklists, and drop down lists. Though convenient it is not a one size fits all option. Care must be taken to make your notes specific to the patient and the visit. Avoid cloned notes and coding at all cost.

Dictation is not the same old paper transcription of yesteryear. Today, the transcription goes directly into the chart via someone in your office or someone you have outsourced dictation to.

Voice Recognition software-Works well, however newer versions don’t sync well with older EMR’s. Look for Medical versions of voice recognition software.

Smartphones and tablets offer options for dictation using the proper various apps with syncing to the cloud and then cut and paste into the note.  In the video I discuss various apps and most importantly, which cloud service is HIPAA compliant.

Medical Scribes-Clinician describes findings to the scribe and they place this information into the patient record.

Typing-Is time consuming and you are likely typing the same things over and over again. Productivity can be increased using a Text Replacement software.  There are various programs available, but my two favorite are ShortKeys (pc) and TypeIt4Me (mac).

And finally, your EMR may offer some sort of mobile documentation app that will sync seamlessly with it, allowing you to manage your patients and documentation from anywhere.

So tell us in the comments, what tools, tips and techniques you use to finish your documentation faster to get home earlier?

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Barbara C. Phillips, NP, FAANP is a professional speaker, author, clinician and business owner who provides business education, resources and support to Nurse Practitioners, Physician Assistants and other Advance Practice Clinicians — both for the employed and self-employed clinician. Additional information about Ms. Phillips is available at www.BarbaraCPhillips.com.

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