Electronic health records transformed medical documentation but often burden clinicians with time-consuming data entry. Optimizing EHR use improves efficiency, reduces burnout, and maintains documentation quality.
Efficient Documentation Strategies
Streamline documentation through multiple approaches. Use templates for common visit types customizing as needed. Employ smart phrases and dot phrases for frequently used text. Master keyboard shortcuts and navigation. Document during visits rather than afterward when details fade. Consider dictation software converting speech to text. Pre-chart before visits reviewing records and documenting planned assessments. Post-visit, complete documentation within 24 hours when recall is fresh. Small efficiency gains accumulate significantly over thousands of encounters annually.
Reducing Copy-Forward and Note Bloat
Copy-forwarding previous notes contributes to bloated, useless documentation. Document only current visit's relevant information. Use addendums for updates rather than editing past notes. Write focused assessments rather than comprehensive histories every visit. Ensure notes contain decision-making rationale and clinical thinking—defensive documentation doesn't prevent lawsuits and makes notes unusable. Good documentation serves clinical communication, not just billing and legal purposes.