Physician Progress Notes and Charge Capture
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 Inpatient Cloud solves the problems associated with traditional paper notes without requiring a large IT project or sacrificing physician productivity.
Shareable Ink Inpatient Cloud integrates to and from existing hospital and billing systems, providing access to the notes in real-time to all key stakeholders.
The note is pre-populated (on the iPad or at the time of printing) 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. CPT and ICD codes are automatically generated based on the clinical documentation, ensuring accurate professional fee coding.
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, payers, 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. 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.