Clinical Documentation Staffing

Physician Engagement and Integrity of the Patient Record in an EHR World

 By Laurie Benz, OP CDI Compliance and Education Manager, MPU

Clinical documentation has come a long way over the last few centuries. The world of paper charts and a magnitude of communication hurdles have now settled into a magnitude of different EHR’s, with separate software programs that support diagnostics, case management, registration and various other departments. Communication with the patients in the past was dependent on phone calls and letters. Now communication has evolved to include email and text messages.

Many have contemplated the differences between the two eras and have leaned either way depending on the success of their EHR implementation along with provider/staff satisfaction.

We are truly in a different world when it comes to how clinical documentation gets into the patient’s chart however the importance of the quality and integrity of the patient’s record has never waivered.

The question I have encountered most is” How will I have time to see my patients if I have to click through all of this to complete my documentation?” Many providers have struggled with this to the extent that either the record stays in an incomplete status in the patients chart or the note is brief with an unspecified diagnosis code because they struggled with the search engine while looking for the more specific code.

This of course is not how they would like to leave their documentation– this is their reality.

How can we help them? How can we encourage the provider to complete their full note or to provide the diagnosis specificity that is warranted based on the patients’ current clinical picture with the barriers they are faced with?


Create type of visit blocks in the providers’ schedule. Well vs. chronic condition follow up vs. new patient vs sick visit. Which type of visit tends to take the most time for the individual provider? Limit the frequency of these types of visits for each scheduled day. Do not put these types of visits “back to back” in their schedule.  Spread them out reasonably throughout the day and the providers schedule for the number of these types of visits. Lock these schedule blocks to inhibit changes by reception staff. Taking this initial step will go a long way in preventing documentation delay and provider frustration.

Documentation Requirement Changes

With the changes implemented January 1st of this year through CMS’s Patients before Paper initiative, ancillary staff may now document the chief complaint, HPI and review of systems. The provider must document that he reviewed the information and notate this in the record.

This is a time saver for the provider.

Look at your current rooming process. Implement changes to facilitate the new requirements.

Look at your end of visit processes. Are there any steps that can be managed by clinical support staff? Referral completion, medication order completion, chronic condition counselling etc.


Pre-Visit Chart Review

Outpatient Clinical Documentation Improvement has become an integral part of outpatient facility and practice environments. We are in a world where more and more payment structures are based on the complexity of the patient’s condition as well as the care that is required to monitor or treat them. As risk share contracts become more and more popular it is more important than ever for providers to not only document the diagnoses to the highest specificity; they also need to document once per year any chronic condition that they are monitoring or treating. Very often patients are seen only for acute conditions several times per year. The provider does review the patients’ chronic conditions however the status or efficacy of the medication prescribed for the condition is an observation based on the patient record and consequently does not end up a part of the patient’s permanent record. We need to help our providers through pre-visit chart reviews, queries, process changes and education. We need to make them aware of these type of conditions or a requirement for specificity prior to or at the time of the visit. These steps will afford a reminder to the provider to document the status of the condition. These steps will also help the chronic condition documentation process become rote memory for the provider lowering the volume of charts that require pre-visit review.

EHR Enhancements

Look at your current templates and diagnosis resource in the EHR. Build the providers template to meet their documentation style. Templates are not one for all. They need to meet the provider’s needs and remain compliant.

Create hard stops in procedure templates to facilitate the completion of procedure documentation through drop down boxes with compliant choices that meet the provider’s documentation style.

Their diagnosis resource or search engine needs to facilitate a search with language that providers use. Many of the resources or search engines are built on ICD-10CM coding book language algorithms creating a lengthy, frustrating non-productive search. Very often the less specific diagnosis is chosen producing an inaccurate clinical picture of the patient resulting in lack of medical necessity for diagnostics and services provided. If enhancements to the diagnosis resources are not a possibility, trend a list of the diagnoses that the provider has the most difficulty with and provide tips on how to proficiently search for each of the diagnoses. As a last resort, consider adding a text box to allow free text of the diagnoses.

Help the provider and the patient

Each and every patient’s complete clinical story is important. The advent of the EHR and interoperability  incentives magnify this not only for healthcare cost savings, but for the quality of care for the patient no matter where they are in the world. It is important for all healthcare providers to remember that the record they provide may be the only record that is shared with the medical community for the patients’ treatment no matter where they are when their medical emergency occurs. Incomplete chart notes or non-specific diagnoses ultimately increase healthcare costs due to duplicate or unnecessary tests as well as, and most importantly, become a liability for the provider and the patient. Non-specific diagnoses or brief chart notes could be the difference between life and death for the patient, especially in instances where their medical emergencies occur in places where their ongoing care provider is not immediately accessible.

It is our role to help assure the continuity of care is paramount and the foundation of every medical practice and medical facility.

Any or all of the recommendations above can ultimately help the provider document all current or chronic conditions that influence the patients’ ongoing care which will definitively have a positive impact on reimbursement and more importantly provide positive outcomes to their patients care no matter where the care is given.

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