What Is The Backbone Of Your Clinical Documentation? We Lost The Meat And Potatoes Of The Visit We Used To See In Clinical Notes.
Documentation has become very cumbersome. There are certain items that must be contained in your documentation whether you provide home health or hospice services. However, with the initiation of the electronic medical record, something seems to get lost. It's the patient. We have beautiful care plans and comprehensive assessment tools available to us in our EMR, but so often the nuts and bolts of patient care isn't clear in what we document. What are we missing? It's the clinical note.
Remember When?
Many of you may not remember the days before the EMR was standard. Those of you who do will note that documentation was much simpler then. One thing was clear though, a clinical note communicated what the focus or skill of the visit was, what teaching was completed, whether the patient or caregiver verbalized understanding/ was able to return demonstrate task, and what the plan for the next visit was. It was that simple. Sure, there were notations if a physician was called or an order was taken, but it was normally easy to know what was happening with the patient over the course of many visits.
How Do We Fix It?
Well, it begins with streamlining the EMR. When we go into agencies, we see an EMR with everything activated in a patient assessment. Now, we are not suggesting you inactivate body systems but you need to look at what your staff is required to document each visit. Staff should go into depth on certain body systems where it makes sense for the patient. But, if your assessments are excessively comprehensive, do you miss the focus of the visit altogether? If you are an agency that has eliminated a clinical note, then how does staff know what happened in previous visits without taking an inordinate amount of time to review? Do they actually do it? In a perfect world, the same nurse or therapist would see the patient every time a visit was made, but this isn't realistic especially in rural agencies. The same concept applies in hospice. Do you need a ton more data or clinically specific documentation that leads to better care that flows from visit to visit? What have you gained by eliminating a good clinical note? We would argue you have not gained anything.
At Kenyon Homecare Consulting , we help agencies to provide high quality efficient care that promotes patient satisfaction and positive profit margins. We can help with strategies to streamline your EMR and clinical operations to achieve it. Call us today at 206-721-5091 or contact us online to speak to a senior consultant for free today!
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