Writing Patient Notes

The Burden of Writing Patient Notes

We recently ran across an article exploring the best times for a physician to write patient notes in their EMR. The article starts with, “Do you feel EMR charting is a burden? Do you struggle to complete your notes on time? If you answered yes to one of those, you’re not alone!”. Charting, writing notes, writing scripts, referrals and dealing with prior authorizations are all logistical pain points for everyone in a medical practice, but especially for independent providers who are also balancing the responsibilities of owning their practice. Why are these tasks STILL daunting, and terribly time-consuming with so much technology at our fingertips? Wasn’t the EMR supposed to be the solution for these problems? Why do providers cringe at the thought of completing records when almost everything about good practice hinges on what should be a simple task. With Eva, our smart medical software, patient notes and medical records become the helpful tool they were always meant to be instead of a recurring nightmare.

Inefficient Patient Notes

Sure, there are some providers who have cobbled together a clinical workflow that makes the best of a bad situation, but this adjustment often requires after-hours involvement and the sacrifice of hours every day. Many have developed such a revulsion to record-keeping that they simply shirk the responsibility and hand it off to staff to piece together some kind of document. One common practice is to “fill in the blanks” and document at the time of the visit instead of interacting with patients. This leaves patients looking at the back of a computer and their provider’s deeply creased forehead.

Ideally, each patient visit would conclude with useful documentation of the entire encounter before they walk out the door. Unfortunately, most EHR’s were developed without input from clinical professionals so instead, these systems mimic the workflow of accountants and insurance administrators. That’s why their user interface is cumbersome, difficult to navigate and nearly impossible to customize.  These systems cause providers to lose faith in their ability to balance patient care with timely documentation.  So, instead of creating notes to maximize quality of care, providers provide documentation for reimbursement, risk management and meaningful use. Ultimately, the medical record becomes less and less valuable when executed for the wrong reasons. 

Efficient Patient Notes

Writing a comprehensive patient note requires consideration of patient status, treatment and outcomes, quality of care, billing, and legal issues. Medical software that’s designed around the doctor-patient relationship integrates note taking into the clinical workflow. This transforms the experience into a collaborative effort that enables real shared decision-making. Eva is intentionally designed to be used in the room with a patient at the time of the clinical encounter. Instead of a personal laptop, Eva works best when deployed on a large touch screen mounted on the exam room wall. This takes documentation to the next level, because it drives patient engagement and collaboration. With Eva, documentation is built into the clinical workflow as part of each visit. This improves the quality of care, makes record keeping a breeze, and dramatically reduces callbacks. You can also prescribe on the big screen during each visit so meds and instructions can be reviewed and discussed. Eva makes it possible for medical professionals and patients to finally and literally be “on the same page!”

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