4 Clinical Documentation Steps Your MAs Can -- and Should -- Do for You

4 Clinical Documentation Steps Your MAs Can -- and Should -- Do for You

4 Clinical Documentation Steps Your MAs Can -- and Should -- Do for You

As a physician, the more time you spend working in your EMR software, the more likely you are to end up hating it. After all, your mission is to take care of patients and make diagnoses, not mess around with routine record-keeping functions.

Fortunately, EMR software is set up in such a way that it’s easy to have your medical assistants step up and take care of routine clinical documentation. Training them to do so and making clinical documentation part of their responsibilities saves time and effort, and lets you focus on what’s important -- meeting with and caring for your patients.

In addition, when MAs take the lead on as many clinical documentation steps as they can, it empowers them to work to their full potential. They are a critical part of the patient care process, and having them take on clinical documentation duties helps make the most of their training and capabilities. 

It's critical, though, to train your MAs not to just ask "has anything changed since your last visit?" As valuable members of the team, MAs have to understand the importance of recording accurate data. And, they have to be held accountable.

Here are four clinical documentation steps your MAs can -- and should -- do for you, plus a bonus tip:

Capture Patient History, Medications and Allergies

This routine questioning is best assigned to your MA, who can easily highlight any changes or inconsistencies for you to question further when you see the patient. 

Past medical history, surgical history, hospitalizations, current medications, allergies, social history and family history are the sections that the MA ought to complete. Be sure to customize your EMR to make this as simple as possible. For example, make it simple for MAs to select the most common medical problems.

For family history, consider setting up a "primary relatives" category within the EMR and give standard choices such as diabetes, stroke, premature CAD, cancer, etc. 

Training your MAs to look at broader categories can help them work at the top of their skill set, while still getting valuable data into the record.

Complete the Review of Systems

The review of systems is important, but repetitive and often not critical. After all, items that are truly positive will be covered in the HPI. Have your MAs take care of this task for you to review at a more appropriate time.

You can easily put together a list of questions for the MAs to ask and customize the EMR to reflect the answers. Taking advantage of modifications this way makes using the EMR software more efficient.

Add Notes on Refill Information

Documentation is especially important when it comes to prescription management, so have your MAs take care of this for you.

Using EMR software makes it easy for your MAs to document this task. MAs can add refill prescriptions under your progress note for your review when you sign it.

Document Literature Given to Patients

If you or your MAs have given the patient any literature regarding medication, treatment or follow-up, have your MA document in the EMR that the patient received it.

Bonus Tip--Have the Patient Enter Data for You

What's better than paying someone else to enter data into the EMR for you? Having the patient enter it. Using a patient portal or your EMR software itself, patients can enter the data directly into the EMR. Most EMR companies provide this functionality as part of their Meaningful Use functionality.

The best way to get the most out of EMR software is to use it -- but it doesn’t always make sense to have the physician be the go-to person for all clinical documentation. MAs should do a lot of your documentation to save you time.

What other documentation steps do you have your MAs complete?

Logan Solutions uses a combination of clinical practice expertise and technological skill to help physician practices throughout the U.S. implement, customize and improve their ERM and Dragon Medical software systems. Contact us to find out how our clinical-practice expertise can help your practice with its clinical documentation software needs.