Clinical documentation is the backbone of clinical operations and patient care. But for most healthcare facilities, it comes with burnout.
One study found that every extra hour spent on documentation in electronic health record (EHR) systems at home led to a two percent increase in burnout.
Here’s how healthcare organizations can build documentation management processes to reduce manual work.
Clinical documentation management
Clinical documentation only works when it covers the right information. Clinical documentation improvement (CDI) specialists review patient records to make sure they’re accurate and comprehensive.
But we can’t look at these documents in a vacuum. Content quality usually depends more on time, or a lack thereof.
So, if we want clinicians to chart accurately, we need systems in place that let them do that.
These processes, protocols, and tools make up clinical documentation management. The goal is to effectively create, manage, store, and maintain all new and existing documentation.
- Processes— The day-to-day workflows and templates that make documentation feasible
- Protocols— This could be setting up suitable access controls to protect patient information, conducting regular audit checks, and interoperability with EHR systems
- Tools—The EHR systems or medical transcription software that standardize document creation and automate manual work.
Instead of ad hoc reminders, reactive strategies, and forcing healthcare workers to introduce ‘Pajama Time’ into their daily routines, formalizing clinical documentation and getting the necessary support ensures documentation quality standards without adding to a healthcare team’s plate.
Best practices for maintaining clinical documentation
Documentation is always challenging in any industry, let alone in one as hectic and interaction-heavy as healthcare.
If you’re a clinician looking to introduce new clinical documentation support to your toolbelt, identify your biggest challenges to prioritize how you want to allocate your resources.
These could be:
- Time constraints
- High volumes of documentation
- Poor documentation training
- Data privacy and compliance concerns
- Disjointed software tools
Clinical documentation management initiatives help healthcare facilities implement consistent and realistic improvements that tackle
Create standardized documentation templates
Provide clinicians with templates that meet a facility’s quality and compliance requirements.
Each template should include fields for all the essential information, along with general guidelines on the length, level of detail, and overall best practices for documenting different kinds of patient interactions, procedures, and observations.
Store these templates in a reliable system that clinicians can access quickly when needed but with access controls and permissions to keep information secure — especially if multiple parties can access the same system.
Build a culture of real-time documentation
Make it a point to consistently encourage clinicians to practice real-time documentation— in which observations are recorded immediately after interacting with a patient.
Healthcare facilities can make it easier for clinicians to complete documentation with transcription software, the templates we just talked about, and having more devices around the facility for clinicians to quickly create and submit their notes.
Real-time documentation means clinicians aren’t spending too much time after their shift cramming in notes, which often relies heavily on memory and can lead to more inaccuracies.
Teach lean document principles
Lean documentation structures notes in a way that avoids spending extra time on unnecessary details.
The principles of lean documentation boil down to ensuring that you document only the most important information.
Clinicians can do this by:
- Identifying the audience and what they need from the document.
- Providing only the minimal, necessary information.
- Drafting an outline or using a template with predetermined fields.
- Leaning on automation tools, like AI scribes.
- Providing iterative and incremental updates.
This simplifies the document creation process and makes it easier for healthcare team members to read, digest, and act on information later.
Adopt a medical transcription software or AI scribe
Medical transcription software turns the doctor-patient conversation into written text, cutting the time spent creating clinical documentation from scratch.
In the past, dictation software would generate raw transcriptions for clinicians to edit later into complete clinical notes.
However, AI scribes generate speech-to-text content to build AI-powered SOAP notes in real time.
Clinicians can quickly customize these documents to fit their required templates. It’s fewer steps with added personalization that you can adapt seamlessly into your workflow and copy/paste into existing EHR systems.
Implement a user-friendly EHR system
A study found that clinicians spent nearly 37% of their day in front of a screen interacting with their EHR systems.
Minimizing your EHR interface’s complexity can make a big difference in the number of clicks a clinician has to make to complete their documentation.
Select a system that makes the most sense for the nature of your team, like the:
- Size of the team
- Volume of documentation typically required in a day
- Tech-savviness of clinicians
- Amount of support and resources available
Depending on how you answer these questions, you might want to consider systems with specific features, integrations, or customization options to improve system navigation and usability.
Conduct regular document audits
Create a consistent schedule to review and audit all clinical documentation for accuracy and compliance.
These audits prevent risk and help healthcare facilities proactively identify gaps in existing documentation practices.
The findings from these documents—both strengths and weaknesses—can help you tailor training programs, improve documentation templates, and inform purchasing decisions for new tools.
Empower clinicians with opportunities for continuous improvement
Ensure that your training programs are not a one-and-done initiative.
From evolving regulations to emerging technologies, EHR system updates, and corrective action for any existing shortcomings, documentation training sessions help clinicians grow their skills and confidence.
Make trainings enjoyable and easy to digest by offering different learning environments, content types, and hands-on activities.
For example, healthcare facilities can allow clinicians to attend in-person or online sessions and build a library of multimedia and interactive resources that clinicians can access on the go for self-paced learning.
Conclusion
As healthcare services and patient needs evolve, so should the processes and protocols that improve documentation efficiency.
By embracing these best practices, healthcare facilities can build a culture of documentation that minimizes clinician burnout through the technology at their disposal.
