You’re not alone if you struggle to complete clinical notes on time. Most physicians spend over 10 hours per week on bureaucratic tasks, which compete for valuable time with patients. For many, the result is after-work EHR time, frustration, and professional burnout.
If this sounds familiar, it’s time to adopt these workflow hacks and consistently complete your clinical notes before leaving the office.
Tips to complete clinical notes on time
An article by Colleen Fogarty, MD, MSc in Family Practice Management, inspired these workflow hacks.
These tips are relevant for physicians with any documentation workflow. But if you’re serious about efficient documentation, consider modern tools like AI scribes or medical speech-to-text software.
1. Leverage the skills of your team members
You don’t have to document everything yourself; adopting a Team Documentation approach can save hours. For example, a nurse or medical assistant can document patient outcomes, review medications, and verify or record allergies. You can quickly review this information for accuracy and sign off on the note.
2. Complete most documentation in the room
When talking with a patient about their health history or treatment plan, summarize aloud as you take or dictate notes. Dictating aloud is efficient and can also engage the patient, improve understanding, and ensure accuracy. Many providers have found that dictating clinical notes during patient visits improves their documentation workflow while benefiting patients.
3. Know the E/M documentation guidelines
You can save a lot of time by only documenting what’s medically necessary to complete today’s visit. For example, a 99213 level of service doesn’t require a comprehensive review of systems or a comprehensive exam. This code is used 61 percent of the time by family physicians seeing Medicare patients.
4. Use time-saving EHR functions
Do you use the time-saving features of your EHR? Templates, for example, are helpful for routine visits where clinical queries are standard. During flu season, save yourself time by creating a basic influenza vaccine template. See more tips on how to optimize your EHR workflow.
5. Let go of perfection
The EHR can be a black hole for perfectionists and compulsive “box-checkers.” Remember the documentation guidelines and keep it simple. Not all boxes need checking; you don’t need to fill every category each visit. Know what matters, and leave the rest alone.
6. Time yourself
Use a timer on your smartphone or watch to see how long it takes to complete a note. Knowing your baseline, set a goal to decrease your per-patient documentation time. Speed shouldn’t be your only goal, and spending more time documenting visits with new or complex patients may be valuable.
Leave the EHR at home
These six tips will help you complete clinical notes on time and leave the EHR at the office. Discover more ideas for reducing after-hours work or learn about the latest AI tools that can write 80% of your clinical note in 60 seconds.