Documentation with Patient
Do everything you do for the patient in front of the patient.
- Dictating Note with Patient: Practice Pearl--invite patients to listen while you dictate (Fam Pract Mgt 2010)
- Texting While Doctoring: A Patient Safety Hazard Distracted doctors can make perceptual and cognitive errors during the medical encounter. Dictation, scribing and assistant order entry can help. (Ann Intern Med 2013)
- If not for the Pause "How much do I miss while multi-tasking, my own hard drive spinning..." (SGIM Forum commentary 2013)
Delegating documentation to preserve time for patient engagement and reduce burnout
- Collaborative Care: A description of nurse-physician partnerships and nurse-directed medical encounters (Dubuque, IA)
- Family Team Care: Making the doctor-nurse team more productive with scribing, delegation and visit preparation (Newport News, VA) (Fam Pract Mgt 2008)
- Optimizing the role of the nurse Nursing Staff: scribing and preparation to improve patient care and productivity (Bellingham, WA) (Fam Pract Mgt 2013)
- Scribes at Shasta Community Health Clinic Physicians report more face time with patients, feel less stressed, and more overall job satisfacation when working with a scribe. (Redding, CA)
Assistant Order Entry
Delegate to most appropriate team members. Reception staff are capable of entering data on requested tests and appointments.
Streamline processes when using EHR: Tips for managing messaging, documentation and order entry with the EHR.
Meaningful Use Stage 2: A nurse or medical assistant can do order entry. This is NOT a physician function. "Any licensed healthcare professionals and credentialed medical assistants can enter orders into the medical record."[