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Documenting Chronic Conditions: Getting It Done Consistently
Joe Nicholson, DO – Chief Medical Officer
Health care providers and health plans have long known about the importance of comprehensive patient care documentation. When care is fully documented, providers and payers get a complete picture of the patient’s health and the interventions being used to manage it. This keeps the patient’s care team on the same page about a patient’s current health risks and care needs.
To maintain this holistic picture, providers should accurately document a patient’s chronic conditions every year. Otherwise, it may appear that the patient’s conditions have been resolved, even when they haven’t. Sometimes it’s obvious that the patient’s condition persists. A patient with an amputated leg due to diabetes, for example, won’t grow that leg back after a year. However, for many chronic conditions, the patient’s current state may not be so clear. A patient with Type 2 Diabetes may be effectively managing the condition one year and experiencing a persistent spike in glucose another year or fall somewhere in between. Without properly documenting the patient’s current state, providers and health plans may not be fully aware of what the patient needs.
Most providers understand the importance of consistent and accurate documentation of their patients’ health conditions. However, it may be challenging to ensure it happens every year, especially if a patient isn’t coming in for a physical or to receive treatment. Without a concerted effort to connect with these patients to bring them into the office, proper documentation is not possible.
So, how can a provider improve consistent and accurate documentation efforts? Here are a few strategies to consider:
Use data to guide proactive outreach. First and foremost, providers should get a handle on which patients have chronic conditions to ensure those patients are receiving appropriate care. By using a data intelligence tool, providers can access a list of patients who have multiple chronic conditions and who haven’t been seen in more than a year. Care coordinators can reach out to these individuals to set up wellness appointments. During these visits, clinicians can assess information about a patient’s health conditions and current therapies to ensure patients are receiving appropriate care.
Remind providers to document at the point of care. Data intelligence tools that seamlessly integrate with electronic health records (EHRs) can use alerts to prompt providers to examine their patients appropriately in order to assess a patient’s chronic condition and then document or dismiss that condition. This way nothing is missed, and the record offers a complete picture of the patient’s conditions and interventions.
Allow more time for physicals. For certain patients, the typical 15-minute appointment might not be sufficient to capture all the necessary information on a patient’s multiple chronic conditions. By using experienced and well-trained physician extenders, such as nurse practitioners, practices can dedicate more time to these interactions, allowing up to an hour in some cases. During the appointment, the nurse practitioners can review the patient’s known conditions, ask about any changes that have occurred within the past year and continue the examination to accurately assess ongoing or new conditions. The nurse practitioners can complete the necessary documentation, order the appropriate screenings and tests, and refill prescriptions as needed. Not only does this help efficiently close care gaps for patients, but it allows physicians to better prioritize their time to work with the patients who require their level of expertise the most.
Address roadblocks that might be preventing access to care. When care coordinators reach out to make appointments, they should pay attention to circumstances that may be preventing the patient from coming in for a physical. This may include transportation, childcare, or work-related barriers. Offering assistance in the form of transportation vouchers and flexible scheduling can make it easier for patients to get a physical each year.
Consistent Documentation Will Help You Deliver the Care You Want to Provide
Keeping documentation current gives the practice a complete picture of the patient’s health. This enables more efficient, effective, and targeted patient care.