EHR documentation requirements and your medical practice

Clinical documentation is the record keeping of patients’ medical treatments, trials, or tests. It must be factual, timely, and specific in its representation of care provided. Clinical documentation is also complicated … and only getting more so.

This blog offers helpful tips to optimize the EHR documentation workflow. You will learn about the elements of good clinical documentation, major EHR documentation requirements, and best ways to document in an EHR.

The importance of accurate clinical documentation

Accuracy in patient health records is all-important. This information informs care decisions, supports evidence-based medicine, facilitates communication between providers, and informs quality metrics.

It also helps billing and coding staff members evaluate claims. About 69% of practices reported increased denials in 2021, an MGMA Stat poll found. In its report, MGMA cited lack of workflow optimization for clinical documentation as a top reason for increasing denials.   

While it’s helpful to encourage patients to review and keep tabs on their own records, providers as well as staff must be knowledgeable about EHR documentation requirements. This may involve reading up on rules and guidance such as CMS documentation guidelines for EHR use. Providers and staff should also be acquainted with clinical documentation steps.

What is a SOAP note?

Do you employ the subjective, objective, assessment, and plan (SOAP) method? It’s a framework for adding notes to patient records or compiling other documentation. Often, SOAP notes serve as a template for adding patient information to the EHR.

These are the four components of a SOAP note:

1. Subjective — how patients describe their health conditions or issues
2. Objective — the record of a physical exam and observation of vital signs
3. Assessment — a summary of the diagnosis, including possible multiple diagnoses
4. Plan — the course of treatment that may include prescriptions, procedures, and therapy

Using a SOAP note, providers can keep track of a patient’s complete information — including exams, diagnosis, and treatment plans — in one standard format. A SOAP note makes the information easier to retrieve and review.

Clinical documentation should capture new information

Clinical documentation is an ongoing process. Providers should make sure they document each exam with the patient and provide the most up-to-date information based on the interaction. If a patient shares information that originated outside the practice — such as a test result or an update about a procedure — providers should capture that information as well.

As providers input information during patient exams, often they may use templates. As they do, it’s important they be mindful of information that will prepopulate and take steps to capture the specifics of the patient’s situation. This may involve removing, changing, or updating certain sections. The goal is to relay consistent information and to avoid instances in which findings contradict one another due to default values.

On a similar note, providers should proceed with caution if they are considering copying a note. This practice may save time, but it can compromise accuracy — presenting past conditions as current, confusing chronologies, or simply misrepresenting a patient’s condition.  

EHR documentation: a shared responsibility

What three things does documentation in an EHR involve that all providers and practice staff should keep in mind?

Here are three approaches everyone can take for better documentation:

1. Communication: Non-provider staff members should communicate consistently about clinical documentation. If there’s an issue with patient records, they should feel empowered to speak up.
2. Collaboration: Often, multiple providers will contribute to clinical documentation. There should be an established process for collaboration and decision-making, as the EHR provides an opportunity for providers to review one another’s notes and see the bigger picture.
3. Keeping tabs: A practice should conduct regular reviews of documentation to ensure providers and staff are following best practices.

Clinical documentation affects not only the clinical exam, but billing and other aspects of the practice. Thus, all providers and practice staff share the responsibility for proper EHR documentation.