Record a note for every consultation
This one is super simple, but whether it’s a compliance requirement or the tool to provide better patient outcomes, you need to record a note for every consultation.
Notes are possibly the least interesting part of running a practice (although if you have gone through all the detail of the clinical note taking best practices series you know that there are significant benefits available by recording notes). There’s always something more important or more urgent to do, and it’s really easy to let consultations go by without recording a note for them. No matter how good your memory, with the volume of patients you will be seeing there’s no way that you can remember each note you’ve missed without a system that keeps on top of it.
The last thing you need when a patient walks into your treatment room is to realise that you missed their last note and you can't quite remember what you did. Or even worse, it's clear that notes are missing when you respond to a regulatory audit of your note taking process.
So, regardless of how you record your notes, you should have a specific process in place to make sure that a note is always taken.
Take action
We recommend the following to ensure every note is recorded:
Make reception staff responsible for reporting and follow up on note recording at the end of every shift
Add processes, reports and tasks to make sure it is easy to see when a note is missing
These actions can are valuable no matter what the size of your practice. Let’s get into some specifics.
Reception responsibility
Add a task to the job of the reception to keep the entire practice up to date with their note taking. This will require the correct reporting and processes to be put in place but will make it much more likely that your entire practice will take all the notes that should be taken. This step becomes more important the larger your practice becomes as it is easier to miss that an associate has fallen behind in their notes.
To ensure clear responsibility take the following steps:
Add clear note taking responsibilities to the job description you have for your reception staff. This should include the need to review note taking on a regular basis (at least weekly) and follow up with staff who get behind.
Add a clear responsibility for the note taking reporting and supporting processes, including ongoing improvements.
Provide reception staff support with tools, processes and reports which allow them to fulfil the responsibility (see below)
Processes
To keep note taking up to date your practice must have the required processes, tasks and reports in place to support yourself and your staff.
Here are some recommendations and suggestions. Note that they are not exhaustive and some may not be relevant or useful in your specific circumstances.
If you take electronic/online notes:
Check to see what reporting is available for note taking in your software.
If there is a specific report which outlines how many notes are outstanding then you will be able to use this to support any other processes you put in place.
With many online systems all you get is an icon against each appointment in your appointment book screen if a note has been recorded. In this case you will need to review the screen at the end of each period (shift or day or week depending on your software and number of practitioners) and record the number of missing notes so you can go back and check in the future.
Some online systems will have no easy indicators that notes have been recorded. In this case you will need to fall back to clicking into each appointment to the client record and then note if a consultation has a note or not. Recording the names of each patient appointment and their note status is the most effective approach in this case, otherwise it will be difficult to efficiently check if missing notes have been recorded in the future.
Reception staff should use what reporting is available to continually track notes being recorded so that you have a clear picture of the note taking position of your practice.
If you take paper notes:
Reception staff should have a daily list of appointments where a patient attends which is checked off as notes are recorded.
Reception staff must be in possession of any recorded notes at the end of each consultation, either they must collect the notes or the patient or practitioner must deliver the notes.
If you use a shorthand notation where multiple consultations are added to a single paper card then the reception staff should review that a notation has been made on the card for the date of the consultation before checking off as recorded.
You will need to consider the privacy implications of reception staff having access to patient notes, but with paper their isn’t much choice as staff will need to handle the notes both before and after a consultation to ensure the correct file is available for the correct patient.
In either case:
Collate end of day position for each practitioner including number of missing notes and number of draft notes
Publish a leader board for note taking in your practice. The simple fact of making status public is often all you need to encourage every practitioner in your practice to get their notes done.
Take your time
There are a number of recommendations here, and this is only the first of the five tenets of effective clinical note taking that we are covering. Take your time as you add these and other changes to your practice. You may find that just collating some figures is a good place to start with other tasks taken once you see the effect.
Want to learn more
This article is part of the series “Effective clinical note taking for Allied Health practitioners”. Please see the other emails in the series for further details and recommendations. If you were sent this link directly and want to subscribe to the whole series, please sign up.