Importance of Accurate Chronic Condition Documentation in Health Care
Physicians and health plans have long known about the importance of comprehensive patient care documentation. When care is fully documented, physicians and health plans 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, physicians 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 proper medical history tracking and documentation of the patient’s current state, physicians and health plans may not be fully aware of what the patient needs.
Challenges in Maintaining Consistency in Documentation
Most physicians 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 physician consistently and accurately document the status of the patient’s health and chronic conditions? Below are a few strategies to consider.
Strategies to Improve Documentation of Chronic Conditions
1. Leveraging Data for Proactive Outreach
Use data to guide proactive outreach. First and foremost, physicians should get a handle on which patients have chronic conditions to ensure those patients are receiving timely and appropriate care. By using data intelligence tools, physicians 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, physicians can assess information about a patient’s health conditions and current therapies to ensure the patient is receiving appropriate care, while simultaneously leveraging that opportunity to close any outstanding gaps in care.
More recently, some AI-enabled platforms have been utilized to also scour historic medical records, including non-structured data fields with free-text to identify chronic conditions previously addressed, not yet addressed during the current calendar year.
2. Ensuring Accurate Point-of-Care Documentation
Remind physicians to document at the point of care. Data intelligence tools that seamlessly integrate with electronic health records (EHRs) can use alerts to prompt physicians to examine patients appropriately in order to assess a patient’s chronic condition and then document or dismiss that condition. Having a consistent record of the patient’s medical history will also provide a more streamlined patient experience. Accurate point-of-care documentation will ensure the notes can later be shared among the care coordinators or with the broader interdisciplinary care team when treating a complex disease. This way, nothing is missed, and the record offers a complete picture of the patient’s conditions and interventions, which also benefits monitoring the patient’s long-term care plan.
3. Allocating Adequate Time for Physicals
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 status of conditions, ask about any changes that have occurred within the past year, and continue the examination to assess ongoing or new conditions accurately. The nurse practitioners can complete the necessary documentation, order the appropriate screenings and lab and diagnostic 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.
4. Overcoming Access Barriers to Care
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. Furthermore, consider offering options such as telehealth services for follow-up visits and staying in contact with patients. Providing a support system centered around patients will help them overcome barriers to care and have more effective and consistent health outcomes.
Conclusion
Keeping medical documentation current gives the practice a complete picture of the patient’s health. This enables more efficient, effective, and targeted patient care.
CareAllies is a pioneer in value-based care with more than 20 years of experience. We help physicians and practices of all types access the right patient data and gain actionable insights to close gaps in care. Learn more about what we do and how our solutions can benefit your organization.