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What are progress notes?
Progress notes are a clinical documentation method that ensures patient compliance in healthcare and allows practitioners to establish a ‘paper trail’ of medical records. Used by over 10 million US healthcare professionals, they record all communication points between healthcare professionals and patients for tracing purposes. The structure of the notes allows for transparency in the healthcare workplace. While it’s true that progress notes are a legal requirement to hold practices and healthcare professionals accountable, they also provide a concise summary of medical information.
If you think this sounds like a tedious process, it doesn’t have to be. They are super effective in that progress notes allow for information to be easily interpreted by healthcare professionals who may need to review it. They can be used for all areas of health, including occupational therapists, mental health therapists, physical therapists, psychologists, and psychiatrists, and can be widely understood due to their universal format. Progress notes make excellent reference points for you and your practice and work towards prioritizing patient needs.
How technology helps in practical progress notes
Technology seems to be everywhere these days, and in terms of healthcare, it’s no different. Technology can immensely boost the quality and effectiveness of medical progress notes and improve the convenience of drafting and finalizing the notes. In many ways, technology is highly integral to the process of documenting clinical notes in the progress format and can provide valuable benefits to you and your healthcare practice. Nuance DAX, amongst other platforms, are perfect examples of how technology is used to enhance how we take progress notes, as it provides various advantages such as:
Using speech recognition - Speech recognition means that all you have to do is speak! Artificial intelligence systems will record everything you say, meaning that you don’t need to reenter information or spend time remembering and writing information as it comes.
Translation and summarization tools - You also don’t need to worry about the little things through artificial intelligence. The technology system will pick up on clinical terminology, as well as correct grammar and spelling automatically. It can summarise information without missing critical details, which saves up to 50% of documenting time.
Quality review and output - Each progress note is automatically reviewed through a rigorous process that checks for accurate information, as well as any omitted data, and whether it is appropriate to the topic at hand. This should give you ease of mind knowing that your information has been checked through multiple processes, thus supplying a helpful progress note.
Voice biometric authentication - For security purposes, the speaker is validated by software and authenticated to ensure that the information recorded is from the proper healthcare professional. This also minimizes the risk of other individuals hijacking or manipulating data.
Information sharing - The rightly designed system will allow for a high level of interoperability between healthcare practices and IT departments, so patient information and data can be accessed in its most recent update.
Features to look for in a progress note software
Now that you’re more up to date on the ins and outs of progress note software, you may be wondering what software is best suited to your needs. Each one comes with a variety of unique features, so to help you get started, we’ve collated some of the most important aspects to keep an eye out for.
Configuration of the software
The software you integrate within your practice should be easily configured to accommodate your needs. Essentially, this means that the software should offer some flexibility by providing customized features that can tailor to your business goals.
Compatibility with other features
Progress note software doesn’t always have everything, and you may find yourself wanting to use other platforms to create the perfect one-stop shop for your clinic. Make sure that the progress notes software you choose can seamlessly integrate with other data you use!
Ability to review documents
Although it may seem obvious, you’d be surprised to learn that many progress note software doesn’t have the ability to review documents. This is especially important for double-checking patient data and for easy access, so make sure that you’re able to utilize this handy feature.
Integration with billing
You’ll also want a progress note software platform that integrates billing and payment features, as this can make for high accuracy and quick reimbursements.
Telehealth note-taking
Progress note software should also include note-taking aspects. It’s an extremely valuable tool to have, as you can produce and store notes from one place, which often follows a template to ensure high quality.
Ways technology can help write progress notes faster
In case you’re unconvinced, using progress notes can also help you take notes much more quickly and efficiently. Using the following features, your progress notes can capture all critical patient information, whilst saving you valuable business time.
Follow a specific format for notes
Progress note software often incorporates embedded templates that allow you to note down all the essential information, without wasting time. You don’t have to spend time sitting and thinking about the aspects you need to include, as it’s all done for you!
Use dropdowns and checklist
Using dropdowns and checklists, you can sort through information quickly, and apply pre-filled details to avoid mindless repetition.
Use voice-to-text features
With voice transcription services, all you have to do is talk into the microphone, and the software will automatically fill in everything you say. It’s a great way to record information without lifting a finger!
Create multiple templates based on case types
Software is a great way for you to create templates according to the type of case, and have greater consistency across your files. For example, if dealing with patients who experience depression, you can curate a template that touches on all relevant aspects, without having to retype this every time.
Use the copy and paste feature wherever applicable
While copying and pasting aren’t advised for every client, as each progress note needs to be specific; there are some areas where this can work effectively. General details and information can be copied and pasted, which can save you tremendous amounts of time.
Consider taking notes after the end of every session
Taking notes after every session is a good way to stay engaged when present with your client, and can also allow you more time to reflect on your conversations. You can note down all details without interruption or distractions, and the quality of your notes will be inevitably boosted.
Electronic Health Record Systems helps through Information Integrity
A significant way that technology can help with progress notes is by managing Electronic Health Record (EHR) Systems, which also enhance information integrity.
Improves documentation capturing - EHR systems improve the capturing of information in systems by long-term storage of virtual data that can promote ethical documentation policies. EHR systems benefit from information if it is not copied and pasted, as this is highly prone to errors. For instance, a practitioner may copy and paste information concerning a patient’s symptoms of depression to another patient, subconsciously unaware that the other patient does not demonstrate all the same symptoms. Or, the copy and pasted information may contain personal information exclusive to one patient, and it’s not picked up on.
Avoids using drop-down menus - Using drop-down menus means that the practitioner cannot accurately capture a patient’s information due to a broad diagnosis. It doesn’t capture the nitty-gritty details that could be critical, so EHR systems are designed around this.
Responsive to hacks - If hacked or overloaded with requests, and this can certainly happen, EHR systems preserve information by having redundant components called fault-tolerance systems. For example, if one element of the whole part failed to work, the system would switch to a backup.
Alerts clinicians - If the information has been misidentified or is unintentionally recorded as something else, such as the wrong blood glucose levels, the EHR system has tools to alert healthcare professionals that there has been an error.
Minimizes clinical decision support system errors - EHR systems promote the safety and quality of various other related support systems by ensuring that information is kept securely and safely. This way, you know that online data and support are based on accurate information.
Electronic Health Records help in Privacy, Confidentiality, and Security
EHRs are also an excellent way to elevate the quality of your practice’s privacy, confidentiality, and security of progress notes. We know it’s essential that when dealing with sensitive information, you need to be particularly tedious with the way you keep records. With EHRs, you can be assured that your patient’s data are held highly secure and private.
Controlled access - Only those who must access information have access to the report, which makes logical sense, right? Surprisingly, most businesses don’t get this right. But EHR systems ensure that patients and practitioners have access to their respective information for high-quality progress notes.
Authentication processes - To increase security, two-tier authentication systems may be used, as well as palm, finger, retina, or face recognition, as well as other biometrics. Passwords must also be set at minimum requirements.
Designation of user privileges - Because each staff member in healthcare practices has different roles, this means they need access to additional information. For example, a receptionist doesn’t need access to patient medical record specifics, but a doctor does.
HIPAA accountability - The guidelines under the HIPAA regulations and rules ensure that practitioners and healthcare employees are held accountable for their actions. This is especially relevant in the case of law and ethics.
Security programs - Educational programs on security and basic software programs such as firewalls and antivirus all contribute towards achieving a high level of protection.
Audit trails - These monitor employees in healthcare organizations to view who had access to information and essentially deal with tracking all system activity. This allows for unusual activity to be detected and suspicious activity to be flagged to prevent security breaches.
Maximize revenue through digitized clinical documentation
Although it seems daunting, digitalizing clinical documents, such as progress notes can have immense benefits for the efficiency and effectiveness of your practice. Practices that use technology statistically earn at least a 20% increase in revenue, and digital notes significantly improve patient care. Technology systems can pick up on human errors. They highlight patient details that allow for more personalized treatment plans and much more accurate clinical health records. Many providers acknowledge that this is such a valuable asset, with value-based reimbursement models becoming more commonplace and paying more to subsidize data-rich systems such as this.
Many healthcare platforms, such as Carepatron, provide digitized software for private practices, all at an affordable rate and at your convenience. With most of the hard yards done for you, these services are readily available to pick up and begin your transition towards digitalization. Especially for clinical documents such as progress notes, these platforms are an excellent option for securing patient information all in one place. But, whatever you may choose, the future is inclined towards progress notes and digitized ones at that. Starting now would boost your practice and guarantee your drive to succeed.
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