Shareable Ink Physician Progress Notes
The Clinical Documentation System that Makes Sense for the Hospital and the Physician
The majority of hospitals use paper-based progress notes for inpatient clinical documentation. These daily notes are written by hospitalists or community physicians rounding on their patients during the inpatient stay. Although handwritten notes are fast and require no learning curve, especially for physicians who may not be in the hospital full time, there are obvious limitations.
With traditional paper notes, it is difficult for all of the stakeholders in the patient’s care to get timely access to the record. These stakeholders range from the community-based primary care physician to utilization review and quality management staff within the hospital. The issue of timeliness is compounded by the fact that most hospitals do not scan paper records until after the patient is discharged.
It is also impossible to extract data from traditional paper notes in an efficient, automated manner. Important quality and billing information has always been embedded within physician documentation, but now there is an increased need to extract quality data for compliance with Meaningful Use clinical quality measures.
Shareable Ink Physician Progress Notes solves the problems associated with traditional paper notes without requiring a large IT project or sacrificing physician productivity.
Shareable Information
The Shareable Ink Physician Progress Notes application integrates to and from existing hospital and billing systems, providing access to the notes in real-time to all key stakeholders.
At the time of printing, the note is pre-populated with pertinent demographic and clinical data for the patient, saving the physician time from looking up the patient’s location or recent lab values. Upon completion of the documentation, several business rules are fired by the Shareable Ink Platform alerting the physician to missing or erroneous information on the form and forwarding an electronic copy of the form as well as individual data elements to multiple back-end systems and work queues.
In this way, communication is facilitated within and outside the hospital. Proactive routing of charts and data saves time for hospital departments that need to conduct chart reviews for CMS, payors, JCAHO, and others. Data can also be routed in a timely and efficient manner outside of the hospital, whether to the physicians’ billing system or in a standardized format (such as CCD) for import into a community-based physician’s practice EHR system. For a group of hospitalists, communication among themselves is made easier through the patient tracking and assignment available in the Shareable Ink Portal.
The results are compelling: immediate access to the progress note by any stakeholder in the patient’s care with simultaneous capture of key quality and billing metrics – all without disrupting the physician’s normal workflow.
- All patient documentation can be automated: initial history and physical, daily progress notes, procedure notes, discharge summary.
- Portability and off-line access allows documentation to be done wherever it is easiest – even at the bedside.
- Alerts for documentation errors are displayed to the physician upon completion of the form – on screen, via email, text message or page.
- Workflow management is embedded, routing pertinent information in real-time to other key stakeholders, such as utilization review, infection control, quality management, medical records and billing.
- Inbound and outbound integration with existing hospital IT systems, including electronic feed into the hospital’s document management system.
- When combined with Shareable Ink Analytics, detailed information related to quality, efficiency and compliance is instantly accessible.
- Productivity is maintained by using the most natural, least disruptive form of data input – pen and paper.
- Charges reach the billing department electronically the day of the visit, significantly reducing days between charge capture and claim submission.
- There are fewer interruptions to the physician days later to complete missing information thanks to the automated alerts at the time of the visit.
- Patient tracking in the Shareable Ink Portal improves communication among physicians and ensures that every visit is documented and charged for each day.
- Hospitalist groups servicing more than one facility can gather standardized data across disparate environments.
- Shareable Ink’s zero footprint software that physicians already know how to use results in an implementation that takes days of IT time compared to months associated with a typical healthcare IT project.
- Real-time feed of completed forms into the hospital’s document management system saves scanning and indexing time, and makes the note accessible anytime, anywhere before the patient is discharged.
- Reduced time and labor costs for quality management and utilization review departments due to automatic, online access to key data on 100% of charts.
- Automated alerts to physicians result in improved documentation compliance.
- Important data for initiatives, such as Meaningful Use clinical quality measures, can be automatically extracted from documentation, aggregated and reported on.
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