Previously we discussed the possibility of documentation tools replacing templates, and in today’s blog post, we are diving a little more into the three major downfalls of patient documentation templates.
Inaccurate Information
Documentation templates are half auto-populated with information, and the other half is left for the physician to populate with patient encounter information.
This leads to three things:
- The document will contain outdated and/or irrelevant information.
- Some document sections will need to be specified in more detail.
- Physicians will tend to use copy/paste methods to populate other templates leading to cloning issues, irrelevant information, and wasting time fixing documents.
“Documentation templates are half auto-populated with information, and the other half is left for the physician to populate with patient encounter information.”
Rigid Nature
Templates are rigid and static; this takes away physicians’ freedom to customize the templates according to their needs.
They are also incredibly time-consuming because they require the physician to write all of the patient encounter information; this leads to three things:
- It takes away from the physician’s focus in the consultation. Also, it consumes a large amount of overtime spent completing the templates leading to a decreased medical care quality and loading the physician with extra paperwork.
- It puts all the work and documentation responsibility on the physician, making it prone to incorrect information and spelling mistakes that can lead to medical errors in the future.
- It consumes a lot of time and effort to be updated and maintained, which decreases the credibility of the information it holds as most of the time, it could be outdated information or wrong information, leading to either starting over with another document or spending a lot of time updating the record.
Legally Incompliant
Templates aren’t standardized. Thus there can be multiple versions of templates used by the physician, these templates might not be legally compliant, and they can contain errors that would lead to jeopardizing the patients’ lives in danger; this puts the physician at risk for extensive legal litigations that can have severe consequences besides its time-consuming nature.
Some templates don’t abide by the legal medical record standards; this can cause issues when the documents are viewed since various parties within the healthcare industry can view them. This includes other members of the treatment team, such as on-call and emergency physicians, as well as colleagues covering for the clinician during absences. Additionally, utilization reviewers, PSRO committees, insurers, and quality assurance reviewers may access the record. In some cases, even a plaintiff’s attorney may be a potential audience for the record.
“Some templates don’t abide by the legal medical record standards; this can cause issues when the documents are viewed.”
Summary
Although medical documentation templates do have their pros, they don’t overturn their cons and their consequences, especially when it comes to making medical errors.
We developed TAPTYPE, a patent-pending digital assessment and documentation platform that physicians and pharmacists can use to comprehensively document their in-patient visits and have a legally compliant and complete documentation note by the end of each visit.
Some of its benefits include the following:
- It saves 79.2% of documentation time since you only need to tap your patient’s answers; TAPTYPE frees up your time to focus more on your consultation and take on more patients throughout your work day.
- It also eradicates spelling mistakes since it has built-in SOAP questions and answers, so you can tap to insert your patient’s replies.
- It uses a SOAP-based interface, and thus it produces comprehensive notes that cover all of the medical consultation areas.
- Its notes are also legally compliant since they contain all the required documentation information.
Learn more about TAPTYPE by contacting us to schedule a one-on-one demo with one of our expert
