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Use best-practice techniques to improve documentation Templates allow for charting by exception, faster documentation

HIM Connection, July 18, 2006

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Use best-practice techniques to improve documentation
Templates allow for charting by exception, faster documentation

HIM professionals are always looking for ways to make physician documentation easier and more convenient-for example, "charting by exception" or using canned text to eliminate the need for physicians to dictate the same routine procedures over and over again.

At North Kansas City Hospital, a pain management physician approached Norma Knipp, manager of HIM. "He was tired of coming to our department so much to dictate and sign," she says. "He said, 'Surely, there's a better way.'" Knipp had the transcription supervisor work with the physician to create a template for each of the pain management procedures that the physician regularly performs. Wherever variables-such as dose or size of needle-appear, all of the possible choices are listed and the physician simply circles the appropriate one for the case.

A transcription clerk then creates the documents. "It's nice because we don't have to tie up a transcriptionist," Knipp says. Once the clerk creates the documents, the pain clinic staff receive the documents when they pick up their records for the day. The doctor signs the documents and the pain clinic staff return them so HIM can route them to match with the outpatient records and "then we're able to take the authenticated document and place it on the medical record," Knipp adds.

The new system works well for everyone she says. "We're happier and the doctor is happier. We don't have to analyze pain clinic records anymore and we don't have to pay a transcription agency for this work."

The process results in about 15 documents a day that take the doctor only about two minutes each to complete, and the transcription clerk only 10 minutes to type up. Before this system, it took approximately four days to turn around pain clinic dictation.

Editor's Note: This article was adapted from Mastering Records Completion 2: More Strategies from Medical Records Briefing, published by HCPro, Inc.

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