The Importance of Documentation
Needless to say, clinical documentation is vital for a number of reasons. It is used to communicate a patient’s medical background to staff, provides evidence of positive outcomes, quality care, and improvement, and determines agencies’ reimbursement claims. Documentation also protects both the provider and the patient.
Ensuring its accuracy and completion is another layer of the process that requires a lot of work from clinicians. Therefore, any challenges that clinicians face will directly affect the quality of documentation. Before identifying a solution, let us first take a look at the issues at hand.
Top Clinical Documentation Challenges in Home Health
- Time spent on the Electronic Medical Records (EMR) charting
Home health clinicians spend extra hours after a 12-hour shift on EMR charting. This can become very frustrating for clinicians in the long run, causing burnout, stress, and even memory loss, among other things, which can compromise documentation quality.
- Incomplete documentation
When something is not documented, it is challenging to recall and take back. While moving too fast and not being able to write out everything is a common occurrence, it does not make it okay. When it is not documented, there is no evidence that you were able to do it. This can lead to inaccurate documentation and can affect reimbursement rates and patient care.
- Unsubstantial narratives
While checkboxes and filling in blanks are easy to do, letting EMRs speak for themselves without a substantive narrative can be dangerous. In cases of denials, one cannot write an appeal letter based on checkboxes. The importance of having a good narrative is that it demonstrates a clinician’s critical thinking ability and shows how care is helping a client make progress toward a particular, measurable goal. Templates and checkboxes can provide information about a patient’s medical history to a certain degree, but we need a person’s entire story to be most effective in implementing successful care coordination and giving proper patient care.
- Incorrect OASIS interpretation
Failure to interpret OASIS questions correctly can impact outcomes and payments even if all the previous steps have been performed accurately. To be blunt, when a clinician misinterprets and is unable to understand the intent of OASIS questions, the agency will not be paid correctly.
What Clinicians Need to Address Documentation Challenges
- Streamlined processes
In the home health industry where a lot of players are involved, it is critical to connect the dots. This means workflows between departments and teams must be streamlined, which can be done using templates and leveraging technology.
When paired with good narrative summaries, an EMR template is an effective tool to create defensible documentation, which can withstand scrutiny from surveyors and other auditors.
Giving clinicians easy access to tools that can make their jobs easier is also a way to streamline workflows. Examples of these are the use of speech recognition tech or just a simplified patient assessment template clinicians can use to systematically jot down information while on the bedside. These simple additions can allow input of information much faster and with greater accuracy, boosting productivity, improving quality, and reducing clinician burnout.
- Better work dynamics
Recent studies published in the Journal of the American Medical Association and Medical Care (JAMA) found that U.S. clinicians spend 50% more time on an EMR than those in other countries. According to the JAMA study, clinicians in the U.S. spend an average of 90 minutes a day actively using an EMR, while non-U.S. clinicians only spend about an hour a day. In addition, it was found that U.S. clinicians spend more time using an EMR after work hours. These findings indicate burnout, stress, and memory loss in clinicians, which can compromise documentation quality.
Staff utilization and clinician satisfaction are key to addressing this problem. One solution is to find an outsourcing partner to assist in electronic charting to ease the load on your clinicians.
- Continuous education
A proactive approach in ensuring quality documentation is continuous clinician education. Maintaining quality and accuracy in patient assessments translated into EMR documentation is a better practice than being able to catch errors and deficiencies.
- Administrative support
While educating clinicians is an effective way of addressing documentation challenges, it can take a while to see real results. Hence, your QA program should be designed to support continuing re-education of clinicians to improve competencies in documentation. It is helpful to have extra eyes to ensure accuracy. Data on clinician performance should be captured and analyzed via periodic reports to get a comprehensive view of areas that need improvement, which when addressed, can contribute to better documentation practices, and ultimately, better patient outcomes.
Clinician Satisfaction = Quality Documentation
Executing flawless clinical documentation prevents compliance issues, financial burdens, and most importantly, errors in patient care. Achieving this is challenging due to all the variables involved, but there are ways for agencies to gain control of their clinical documentation quality and accuracy. In general, better observations mean fewer mistakes. All efforts poured into this objective are worthy investments that can positively impact an agency on all fronts, from good patient outcomes to business growth.