Empower Your Practice

Journal for Practice Managers

How to Organise Your Electronic Health Records and Produce Perfect Documents

Michael May
February 19, 2020

Organise EHR

Electronic health records are now an integral part of documenting your patients’ progress. The whole purpose of an EHR is to have a digital repository of information about every single one of your patients. You can bring up their medical history, including diagnoses, prescriptions, test results and more at a click. If you take a step further and opt for a secure cloud-based solution, then you can access all your patient data at any time in any location. Creating and storing digitised paperwork has never been easier!

When you first started out, you may not yet have realised how much time and energy it takes to fill out all the paperwork that gets generated while you provide quality care, even in the digital world. I am sure that you and your colleagues have found yourselves complaining about your workload from time to time, and I bet that the majority of these concerns have been to do with admin and paperwork. Fortunately, the digitisation of medical practice management and indeed healthcare as a whole means that you can have this weight lifted off your shoulders if you take the right steps.

Having comprehensive practice management software in place in your clinic will help you streamline your workflow and achieve a much better work-life balance.

To show you what you are missing out on by not combining your EHR with a practice management system, we shall look at the following:

  • How to automate as much admin work as possible
  • How to complete documents with minimal time spent
  • How to record medical information concisely and comprehensively

Read: How to Automate Your Paperwork in 5 Simple Steps

Automate Your Admin in 3 Steps

Chances are, you spend way too much time on admin tasks that are important but incredibly tedious. After all, how many times can you copy out the same information before there’s just about anything you would rather be doing? Luckily for you, automating your paperwork completion is far easier than you might have realised. Here’s how to do it.

1. Identify Your Information

First, you need to understand that there are two types of information that you are dealing with on a daily basis:

  • Static information that does not tend to change or vary
  • Dynamic information that does change depending on circumstances

Static information typically changes only as a result of very specific circumstances, so you will find that in the vast majority of cases, you can expect to be able to use this information over and over again without risking any inaccuracies. Naturally, as with everything, there are some exceptions to the rule but to ensure your optimal understanding, we’ll cover those as we go through these 3 steps of automation.

Here are some common examples of static information used in healthcare:

  • Patient names
  • Dates of birth
  • NHS numbers
  • National Insurance numbers

As you can see, these things will not usually change. Of the four examples given above, it is only the patient name that may be subject to change as a result of life events such as marriage or divorce. I’m sure you’ll have one or two cases of your patients changing their name by deed poll as well, but that’s something of an outlier compared to more usual circumstances.

Dynamic data is by its very definition in constant flux. This is the kind of information that cannot often be predicted in advance without the risk of being inaccurate. As such, dynamic data is usually recorded manually even in the digital world.

Here are a few examples of dynamic information that should expect to encounter:

  • Dates and times of events, e.g. appointments, procedures
  • Newly prescribed medications
  • New diagnoses
  • New document content, e.g. referrals, prescriptions

Your first task is to separate the information you are using into those pieces that need to be entered every time (dynamic) and those that can be safely brought through to the final version of your documents without any direct input from you (static).

In actual fact, when you choose the right electronic health record tool, you won’t really need to carry out this task all by yourself. For example, in the case of Medesk, our experts plan a discussion with you to understand exactly what documents you need to use and how you intend to do so. From there, we can understand how much of your document can be built automatically every time, and how much should be placed in a time-saving template for you to complete.

Medesk has more than 60 ready-made forms for use in 24 medical specialties. Our intuitive template editor lets you create individualised templates that work just the way you want them to.

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Read: Top 10 Practice Management Software Features You Need to Be Looking for in 2020

2. Create Comprehensive Patient Records

A smart EHR tool will have a wide range of different data entry fields for you to use. Adding a new patient record enables you to have a base from which to understand everything about your patient from their medical history through to documents uploaded, forms filled out and invoices paid. In short, your electronic health records should extend far beyond the basic medical facts.

Even an empty patient record will contain a comprehensive set of static information that you can use to generate documents in the future. This information will typically be personally identifiable information (PII) that needs to be protected by means of an encrypted and secure practice management platform.

Patient records should contain the following PII at the very least to ensure proper document creation:

  • Patient forename and surname
  • Date of Birth
  • Contact details
  • Home address

The ideal patient record should comprise several sections that make use of all the information you have been inputting ahead of time. Make sure that your EHR contains the following:

  • Medical history

    • You need an account of all the medical events that happened to your patient alongside all the actions that were taken.
    • It is ideal to have a medical history organised in chronological order so you can find specific information quickly.
    • Being able to copy previous comments through to your current notes is very helpful as it saves time and refreshes your memory all at once.
  • Forms and documents

    • You require a place to create and store the mass of documents that are completed outside of appointments.
    • Sort through documents and correspondence according to the type of templates used, e.g. repeat prescriptions, referral letters.
    • Print perfectly formatted documents in a few clicks or save as a PDF for purely digital use.
  • Uploaded documents

    • Making the transition from paper to paperless is much simpler when you can scan in and store digital copies of documents directly in the patient record.
    • Store and view images without having to download them to your computer, e.g. ultrasound images, photographs of skin lesions
  • Invoices and billing

    • Your patient records should be a full account of your patients’ standing in your clinic from the point of view of their being clients.
    • Keep track of outstanding debts and payments for ongoing treatments to ensure that you can keep your practice alive and thriving.
    • Produce invoices, receipts, credit notes and more to ensure that your patients can trust your practice as a business as well as you as a clinician.
  • Communications log

    • Keep an eye on all outgoing traffic from your patients’ electronic health records, be they texts or emails.
    • Track automated booking confirmations and reminders to ensure they are sent correctly and help you reduce cancellations.
    • Write one-off texts and emails with the help of custom templates to balance personalised communication with efficient work practices.

The Medesk EHR module is so much more than just a patient record. You’ll benefit from a wide range of handy tools.

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3. Set up Smart Data Entry

By the time you have properly created patient records and started looking at even the most basic documents in a practice management system like Medesk, you will notice that your patients’ details are cropping up in a range of appropriate locations. To make the most of this automated data entry, you’ll need to ensure that your data entry and document handling work is second to none. Fortunately, the best software providers assign you an account manager to help guide you.

Alongside comprehensive patient records, you need to have consultation notes and other document templates that give you scope while being as efficient as possible. The ultimate goal is to be concise, getting the maximum amount of easily understood information into your work with the least amount of energy wasted.

Read Case Study: How Practice Management Software Creates a Healthy, Transparent and Dynamic Culture in Our Clinic

Here are some examples of how you can make the most of templates to generate excellent documents every time.

  • Drop-down lists

    • For when you want to select one option from a long list
    • Ideal for lab tests
  • Yes/No switches

    • For direct questions
    • Ideal for patient surveys and questionnaires
  • Buttons

    • For logging symptoms and signs
    • Ideal for systematic reviews and multiple responses to one question
  • Rich text editor

    • For just about anything from pure text to tables and lists
    • Ideal for lab results, formal reports and comments
  • Units of measurement

    • For saving time finding the exact units you need
    • Ideal for logging lab results, BMI and more
  • Drug entry via the BNF database

    • For making sure you prescribe the correct drugs quickly
    • Ideal for formatting prescriptions in mere seconds
  • ICD-10 entry for precise diagnosis

    • For formal diagnosis and access to specific NICE guidelines
    • Ideal for reporting specific diagnoses and how they were treated
  • Times and dates

    • For timestamping, dates of birth, appointment dates and more
    • Ideal for practically every document you use

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Excellent Patient Care Based on Firm Foundations

All of this preparation sounds like a lot of work but anything worth doing is worth doing right, especially when it comes to your patients’ health and that of your clinic. Get the help of a practice management expert when planning your approach to digital health and you can expect your clinic to thrive.

Follow these steps with the help of your advisor:

  1. Examine the kind of patient data you possess
  2. Sort what can be automatically added to documents and what cannot
  3. Organise your patient records systematically
  4. Create document templates to manage new information
  5. Combine templates and data to create comprehensive documents for all occasions

Read How to Utilise Electronic Health Records to Optimise Patient Care in Private Practice

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