What are effective strategies for streamlining clinical documentation in a busy healthcare environment?

Templates are a great tool to standardise processes and streamline work flow Thing about what you are capturing and using them for as it may be better to use excel so you can analyse the data, identify trends etc

In care management, efficient clinical documentation is crucial. Utilizing templates for common cases, employing voice recognition software, and regularly updating documentation protocols can significantly streamline the process. Additionally, ongoing staff training ensures proficiency in documentation tools, reducing time and errors.

As an RN functioning on the front-line, in the clinical setting, it is imperative to have a functional template for clinical documentation. SOAP and SBAR are both highly efficient and effective templates for communicating within a clinical healthcare team. They create a flexible format to coordinate healthcare at all levels. Adherence to their protocols, timely updating of pertinent information and healthcare status are essential to quality documentation, within any healthcare team/system. The clinical documentation may be extended to billing, coding, quality improvement, and research.

Healthcare is being flooded with technology, without benefits to the healthcare professionals. Being pressured on time, the extra documentation is not helping them. Luckily, new technologies are emerging. Not just to add to the tech stack, but that can bring true value to the clinicians and the patients. I have yet to come across someone who enjoys documentation. Imagine automating this process. The consultation can be recorded, and based on the recording artificial intelligence tools can help logically structure the documentation. It can highlight important information, adding certain measures to graphs, so that the clinicians can see progress over time. We should think about tools that benefit all, not just adding to admin tasks.

Collaboration is an integral aspect of knowledge exchange. When I hear “busy healthcare environment”, my mind pictures a stacked inter-professional team with a rich diversity of clinical disciplines. Having a proper understanding of the role each member of the team plays creates awareness of the type of work each member does & gives respect to the individuality within each role, & also recognizes where they may be overlap. This can help us to make better use of our time I.e: If both myself & a coworker’s role involves assessing a patient’s mental status, we would likely be spending time capturing & documenting the same information. Here, it would be beneficial to work out a team-specific process that allows us to reduce that overlap.

Delegate and collaborate isn't as simple as just providing a space for people to meet. Guidelines and procedures that outline how to collaborate and where individuals jobs start and finish and other individuals take over is a key to a high successful collaboration approach in healthcare. These don't need to be complex webs of responsibility but simple documents that outline the key role in the individuals responsibility when collaborating.

Reviewing your processes can help with staff development and training and finding what works for your team. Getting your staff involved with this can aid retention as well as giving you additional changes to consider.

The review process should include how staff is using the documentation; the clinical documentation must reflect the real-time situation when used to avoid conflicts and maximize care delivery. This is a team sport, and we are all in it. Each member of the healthcare team is responsible for ensuring timely recording. I recently observed a morning "Huddle/Transfer" at a major academic teaching facility during which the 2nd shift RN caregiver "could not remember what time she gave the patient a pain medication." How is that possible, if we are using the process correctly?

Ensure that your team has access to the resources, tools, and information they need to complete the task successfully. Establish milestones or checkpoints along the way to monitor progress. This allows you to intervene if necessary and ensures that the project stays on track.

Effective clinical documentation improvement demands comprehensive clinician education and training, including standardised templates, technology tools, and best practices. Clinician training reduces documentation errors, improves workflow efficiency, and minimises rework, leading to long-term cost savings. This education, in turn, empowers clinicians with the skills to effectively and efficiently document patient encounters, improving job satisfaction and reducing burnout. Clinicians who are appropriately training will produce accurate, complete, and timely notes, directly benefiting patient care. This leads to more effective collaboration amongst the clinical team, improved diagnosis and treatment planning, and overall patient outcome.

Leverage clinical connectivity via FHIR APIs, SMART on FHIR applications that integrate to EMR, and invest in a care management team to utilize actionable insights to engage with the patients that are not coming to the doctor.

If practitioners understood that their clinical notes are an extension or representation of their “brand,” they will use all available resources to make sure things are documented timely properly. They will be motivated to refine and become more efficient on the care they provide to others as evidenced in their documentation. They need to be rewarded for their excellent clinical documentation. This will provide greater “brand” awareness to their practice because it shows in the way they document.