Tips For Efficient Medical Documentation

Medical documentation is one of the biggest contributors to practice inefficiency. On average, clinicians work over 50 hours a week and see 20 patients a day. Since the length of a typical patient visit is around 15 minutes, that means less than half of their 50 hour work week is spent actually seeing patients. The rest of that time is spent in front of a computer screen entering patient data into an EHR. 

This has given rise to a number of tactics aimed at shortening the amount of time spent on notes. One of the most common is copy-forwarding, or populating a patient chart with the notes from a previous visit and editing from there. A recent study found that in a typical note more than 45% of the content is copied, while only 18% is entered in manually and 36% is imported from another source (ie. medication list).

While copy-forwarding feels like an effective way to expedite the note-taking process,  the increased risk for including outdated or unnecessary information often makes it counterproductive. In 2016, fees incurred for improper payment rate for Medicare exceeded more than $40 billion – in large part due to incorrect coding, insufficient documentation, and inclusion of unnecessary information. 

Copy-forwarding is just one of many tactics employed by clinicians in an effort to spend less time on documentation and more time with patients. Fortunately, there are other (more effective) solutions. Here are 4 ways to maximize the efficiency of your documentation process without jeopardizing the quality of the notes themselves. 


Delegating allows you to use your time more effectively by reassigning tasks that do not necessitate a medical provider to perform. When it comes to medical documentation, prime candidates for delegation include verbatim transcription of the patient visit, organization of notes, and data entry into the EHR. 

One of the most common practices for delegating documentation work is to employ a medical scribe. However, for many clinicians, scribes are cost-prohibitive – ringing in at around $50,000 annually. 

Recommended: Virtual Medical Scribes: The Good, The Bad, And The Ugly

Another way that providers can delegate documentation is through the use of dictation software, which converts dictated speech to text. While this delegates the task of typing, you will still need to summarize and edit your notes to ensure accuracy. 

One of the most effective ways clinicians can delegate is to leverage an AI powered scribe. Unlike dictation software, AI scribes can handle note-taking completely autonomously, and they do so at a fraction of the cost of a human scribe.

Optimize Billing.

Taking EHR shortcuts not only impacts the efficiency and accuracy of your notes, it can also impact your bottom line. If you regularly speed through notes between patient visits, you are more susceptible to undercode and lose out on potential revenue or overcode and risk insurance penalties. 

How To Avoid Undercoding & Maximize Billing:

As many as a third of patient visits are undercoded, a common mistake that cost healthcare providers as much as $1.2 million in 2016. The leading cause? Insufficient documentation.

To avoid undercoding and maximize billing, look out for these common mistakes:

  • Missing information: For example, the date of an accident, emergency, or onset of condition
  • Lack of full diagnostics: This includes greater detail around the severity of a condition in order to receive full reimbursement
  • Lack of procedural specificity: Make note of all procedures performed and any complications that arise.

Should you choose to delegate your documentation process to a human or AI scribe, these details will be captured for you. No longer will details be missed or forgotten after a full day of seeing patients or from closing charts days later. Perform a quick check for these common faux pas before you sign off and move on to your next visit.

Schedule Time For Monotasking. 

When completing a mundane and repetitive task like EHR data-entry, it’s tempting to knock out another task simultaneously. However, every time we turn our attention to a new task like checking email or responding to text messages, we incur a brief mental block that decreases productivity by up to 40%. And if that’s not enough to convince you to kick the habit, research has also linked chronic multitasking to shrinking grey matter in the areas of the brain that control empathy and emotion. So long, bedside manner!

The solution? Monotasking, or focusing on only one task for a set amount of time. An easy way to make monotasking a habit is to start by blocking off time on your calendar specifically for note writing. When the time comes, put away all other distractions and commit to only completing patient notes. 

Start small by only setting aside as much time as you can maintain uninterrupted focus for – the more you practice, the easier this will become. As you strengthen your ability to monotask, you’ll start to see a dramatic decrease in the amount of time it takes to complete your notes.

Get the Free eBook: The Complete Guide to Medical Documentation Solutions

Follow the 2 minute rule. 

Once you master monotasking and begin delegating the bulk of your medical documentation, you can implement the 2 minute rule. The 2 minute rule is the brainchild of productivity expert David Allen and simply states that “If it takes less than two minutes, do it now.” 

Large tasks can be daunting but are much easier to tackle if broken down into smaller sub-tasks. Rather than thinking of your mounting paperwork as one large to-do list item, consider each individual chart you must complete and the smaller tasks they require. This will be made easy if you delegate your work to an AI scribe, as you will only need to review and sign off on the notes that are prepared for you. 

So there you have it, 4 steps you can implement today to increase the efficiency of your documentation process and restore patient-centered care to your practice. By delegating, monotasking, optimizing billing and following the 2 minute rule you will dramatically lower time spent on documentation while maximizing the efficiency of the time you do spend.

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