I’m going to describe something that should be very familiar to you. It’s something you use most days you work, whether you’re seeing patients in the office or via telemedicine. You might even use it more often than you use your stethoscope or otoscope. What is it? An electronic medical record (EMR) system.
Odds are that you did not select the EMR that you use every day. Even if you were lucky enough to select your own EMR, your choice may have been limited by cost. So, not only are you required to document via EMR, you may be using a system that is not intuitive to you.
Research has shown a relationship between EMR use and burnout, a major issue among medical professionals. So, how do we lower the risk of burnout by reducing EMR burden? Read on for some of my tips.
- Identify hangups. Envision your workflow process. What prevents you from finishing your note immediately after seeing your patient? Ask management to take steps in mediating this. This could include adding documentation tools such as tablets, desktops, or dictation devices in certain areas that may help streamline your process.
- Seek recommendations. If you work in a healthcare system where an EMR representative is available, ask them to observe your workflow and documentation flow to see if they have any recommendations specifically for you or your clinic.
- Use shortcuts. Ask your EMR expert or another clinician advanced in EMR in your clinic to show you some of their useful shortcuts. These can include how to insert pre-typed phrases, import data sets, or upload note templates per diagnosis.
- Find a scribe. Train someone to scribe for a portion of your note in real time when possible. This can include your assistant, a scribe, or nurse.
- Don’t wait. Work on your notes in real time or shortly after visits. Block time to work on notes at regular intervals. Do not let them pile up or save them for later.
- Be clear and concise in your documentation. Bullet points are ok if your EMR supports this.
- Combat “note bloat.” Disable auto-population of unnecessary information by the EMR in your note settings if this slows you down.
- Utilize shortcuts. If you are able, make shortcuts for common orders and common procedures. Creating new shortcuts may be time intensive initially, but it will end up saving you time in the long run.
- Get involved with your national medical society’s task force to collaborate with EMRs to make them less cumbersome.
EMR is an evolving new reality in healthcare. Fortunately, many clinics are making strides to decrease the EMR burden it places on clinicians. I hope these tips help make your documenting job a little easier so you can keep focusing on what really matters: giving your patients the care they deserve.
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