How To Improve Clinical Documentation Processes in Patient Records Management

When it comes to managing patient records, the healthcare industry has come a long way. For the most part, the days of the paper chart, appointment books, and Rolodex files filled with patient information are long gone. Electronic medical records have made it possible to simplify patient records, and streamline them into a system that’s getting better and better every year.

However, even though EMR has provided many technological advances that have allowed physicians to provide better care to their patients, in many ways, it’s still lacking. One of the areas that would benefit from a degree of improvement is clinical documentation. Today, we’d like to talk about how synoptic reporting can work to help your medical facility streamline clinical documentation that will make it more beneficial for your staff, as well as for any hospitals or practices you may refer to.

Elimination of Medical Transcription

In the past, using a transcription service or employing a complete transcription department was the standard practice in most hospitals and medical facilities. Surgeons would complete their cases, jot down a few notes, and then either leave the room and dictate their notes, or put them in a pile to be dictated at the end of the day.

This resulted in the loss of a great deal of information, and many patients’ medical records were incomplete because of the inefficiency of this method. When synoptic reporting is used, the patient’s record can easily and quickly be updated during the patient encounter or immediately thereafter, thereby eliminating the need for transcription altogether and saving the clinician valuable time. Notes are inserted into the chart immediately, and they are easily accessible by any member of the staff.

Structured Data Through Templates

In transcribed reports, and even when using some built-in features of EMR systems, narrative reports are created for patient records. In recent years, physicians have realized how inefficient this type of reporting is, especially when doing research to measure patients’ medical outcomes, as well as comparing and contrasting data between patients. To improve clinical documentation, synoptic reporting uses templates in place of the narrative method. The use of these templates has proven to be very effective, resulting in more complete notes that use streamlined medical terminology that is also easily searchable.

Analyze Data to Measure Patient Outcomes

As more healthcare regulations are passed, it has become necessary for physicians to measure medical outcomes for the purpose of improving the level of care they offer to their patients. Narrative reporting presented many challenges, and it was nearly impossible to search through reports to find the information physicians needed when compiling data.

At times, the necessary information was missing altogether. Synoptic reporting provides an excellent alternative because it is designed to promote the ability to search data easily. This searchable data can be cross-referenced, and because it is organized and meaningful, it provides a great benefit in that researchers are able to identify best practices and improve patient care even further.

Additional Benefits of Synoptic Reporting

Synoptic reporting carries a host of other benefits as well, including:

  • Eliminating transcription costs
  • Providing alerts to physicians regarding patient care tasks
  • Allowing nurses to compile drafts for easy approval
  • Promoting information sharing and knowledge transfer between physicians, facilities or practices

These benefits have already improved patient care for many medical facilities, and it can do the same for your hospital or practice.