As a healthcare provider, keeping thorough medical records is part of the job. Unfortunately, writing down information like operative and progress notes and lab results can be time-consuming. The following advice will help you increase the efficiency of medical documentation, allowing you to devote more time to patient care.

How to Improve the Efficiency of Medical Documentation

1. Use Bullet Points

Instead of writing long sentences in clinician notes, separate the information into bullet points. You can summarize the details, provide further instructions or directions, and keep the information organized. This approach will make it much easier to recall details quickly when you review the notes later and relay the information to colleagues.

2. Try Dictation Software

Even if you use a tape recorder to take notes, transcribing the audio later will still take time. Simplify the medical documentation process by installing dictation software on a computer, tablet, or smartphone. 

You could also use the built-in features on electronic devices. For example, the Windows 11 operating system has a voice typing tool, which can be activated by clicking "H" on the keyboard and the Windows logo. If you are using a touchscreen, press the microphone key. To turn off voice typing, tap the same key again on the touchscreen. 

3. Prioritize the Information

Having specific goals when writing clinician notes will ensure all essential information is included. The memos should contain, for instance, details about the continuity of patient care. This way, you can track the quality of care over time. 

All services rendered must always be added to the notes. This ensures the billing department has the correct facts to send to the patient or insurer for payment. The memos should also contain information that can protect you from liability. Therefore, write down the reasoning for treatment decisions, the discharge facts provided to the patient, and details about informed consent discussions.

Delegating is another step you can take to increase the efficiency of medical documentation, which is why you should contact the professionals at My Virtual Scribe in Camarillo, CA, for assistance. The company provides virtual medical scribe services for health clinicians in the United States and Canada. Their assistants are trained, licensed, HIPAA-certified medical professionals. Learn how they can help you boost operations and patient care online, and call (310) 919-4278 to get started.