Working from the Ground Up: Why Documentation is the Key to Practice Success – Part 2

Jacob Lynch Electronic Health Records (EHR)

Doctor Using Laptop And Electronic Medical Record (emr) System.

Part 2 – Getting Started: How to Begin Your Documentation Project

I like to say that documentation is like pain medication, start low and go slow. The first step is to decide where and how the practice will provide documentation. As we discussed in Part 1 of this series, an intranet site is an easy, efficient, and reliable way to share information with staff. Once you have thought about the formatting and storage of your documentation, it is time to dive in! Here are a few tips that will help you get started and keep moving along.

Start with a simple process.

In terms of creating documentation, it is best to start with the low-hanging fruit. This would include tasks that are small and do not require much training for staff. By starting with a simple workflow, you can test out your documentation format and build confidence as you write.

For example, every patient needs a height, weight, and blood pressure measurement at every visit, whereas a temperature is only required for certain patients. In this case, your workflow might state that staff must measure the height, weight, and blood pressure for every patient, but they would only collect the patient’s temperature as part of the vitals if the patient feels ill or has a wound.

Here are some other good places to start in terms of documenting simple processes:

  • Checking a patient in for an appointment
  • Rooming a patient from the waiting room, collecting history and vitals
  • Arranging for interpreter services
  • Registering a new patient
  • Triaging and scheduling new patients
  • Arranging for services ordered, such as an MRI or other procedures
  • Answering and routing telephone calls
  • Completing patient-provided forms, such as FLMA paperwork

At first, your documentation may not require staff to make any changes to how they are working. It will simply reflect their current practice. As challenges arise, the documentation can be amended to address any gaps. You will be surprised at how fast the documentation will grow.

Consider any possible exceptions.

When creating documentation for a workflow, be sure to think about the ways in which the process might break down. If possible, try to identify those points of failure in advance. Look out for edge cases! Staff members are usually a great source of examples where processes do not always work as intended.

If there are common exceptions to a process, be sure to build those into the process. If there are rare exceptions to a process, it may be best to add those in a separate “call out” box so staff know that they will need to handle those situations differently. Build your workflow documentation so that it is easy for staff to do the correct thing. When the correct way is the easy way, compliance will become nearly automatic.

Pick the right time to make big changes.

Sometimes there are immovable external deadlines driving change in practices. But if you have some control over the situation, try to optimize the timing of your big changes. It is not always easy to push a big change on providers and staff when they are busy and feeling overwhelmed. Here are some tips related to the timing of changes:

  • Use slower times to implement big changes. For many practices, late summer and the last week of the year are good times for big changes.
  • If a change is too large or complex to do all at once, consider rolling out the change in phases.
  • Trials are another good way to test big changes. If the practice has 20 providers, perhaps a single provider and his or her support staff can implement a process change for a week or two and provide feedback that can be used to refine and improve the process for others.

If a change is not mandated, sometimes it is best to hold off until the timing feels right. Changes will be much more successful when everyone in the practice is invested and recognizes the benefits.

Find your champions, forward-thinkers, and allies.

Quite often, staff and providers are the best resources for ideas on what to fix and how to fix it. As you create your documentation and make changes to existing processes, be sure to obtain feedback along the way. Sometimes there is a fine line between inviting staff input and opening up a floodgate of complaints and negativity. For staff who are typically resistant to change, it may be best to exclude them from the conversation until the change is more defined.

If you have staff and providers who are forward-thinking and engaged in the change process, then invite their input as early as possible. They can be a great resource to help develop more efficient and safer workflows. Seeking staff input is also a good way to groom your high-performing individuals for future leadership positions.

Peers at referring practices and partner hospitals are also valuable resources. In some cases, workflow documentation can be tailored to coordinate with other providers that your practice works with on a frequent basis. Just be aware of Stark Law considerations.

As you move forward with creating documentation and implementing changes, hopefully you will start to see more efficiency and higher staff morale in the practice. Next time, we will move beyond creating documentation into the maintenance phase and show you how to keep it all together.

Did you miss Part 1 of our EHR Documentation series? Check it out here: Working from the Ground Up: Why EHR Documentation is the Key to Success.