How to Complete EHR Data Entry By the End of the Appointment

Doctors at all types of practices are faced with a challenge. They need to provide focused and attentive care to patients while also performing EHR data entry. Not only is it important for MACRA compliance, but a well-kept patient record helps build relationships and improve care quality. The trouble is, humans naturally have a hard time focusing on more than one thing at a time. Since care is the number one priority, many healthcare professionals end up taking quick notes and completing their EHR updates later.

That tactic is manageable… but not sustainable. Nobody wants to be stuck in their office doing EHR data entry for hours after their last appointment ended.

Making some process changes could significantly reduce EHR data entry time. Here are five strategies that physicians can use to improve their agility when it comes to record entry.

Perform Basic EHR Data Entry Before Entering the Exam Room

On the way into the exam, doctors should take a moment to check the patient’s most recent complaints, treatment activities, and other notes. Gaining a little context before the appointment can help providers ask the most relevant questions. It’s also a good way to confirm the patient’s identity at the start of the appointment and make sure the correct record is open. Doctors can also get the basic information out of the way, like logging the appointment date and reason for the visit.

Let the Patient Dictate for You

With the right open-ended phrasing, providers can lead their patients to do most of the talking. After patients complete their statements, the doctor can summarize the most clinically relevant information, and communicate it to the patient. That summary can also be written out simultaneously in the EHR. The patient gets the benefit of having an attentive listener followed by a clear explanation, and the record gets filled out without heavily interrupting the appointment.

Choose the Best Template for Your Needs

Many EHR systems will allow users to create unique templates. Templates feature a specific set of fields that are most applicable for certain practice areas. In some cases, they can be more easily navigated than a general record. Of course, some EHR systems make customization and general use really difficult.

Some practices may opt to go with a different EHR vendor altogether. They do feature different interfaces. A complete changeover can be difficult to achieve, though, so many providers will find it easier to utilize a third-party solution, like a mobile EHR app.

Substitute Talking for Typing

Not everyone is a strong typist. In time-sensitive scenarios where quick notes need to be taken, like during an appointment, speech-to-text tools may be a better choice. This can work in conjunction with the recommendation from above, where the doctor summarizes the patient’s input. It also provides an extra element of patient participation in that patients know exactly what’s being entered into their record. They can also potentially catch errors and correct them immediately.

Explore Predictive Medical Terminology Software

A predictive text solution that’s built specifically for healthcare can also help cut down on EHR data entry time. It may take some investigation to find a system that leverages this technology, but the benefits make it worth looking into. Not only will record completion be faster and more accurate, but providers can know they’re leveraging a core set of clinical terms, which can make coding for invoices easier.

Mobile EHR apps like iScribe come packaged with several features (including predictive terminology, speech-to-text functions, and an easily navigable interface) that allow doctors to complete their EHR data entry by the end of every appointment. To learn more about how mobile enables healthcare providers to deliver better care, click here and download the Ultimate Guide to Mobile in Healthcare.


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