Doing Documentation Right: A Balancing Act for Physician Practices


Medical group practices often go full speed ahead once they decide to implement an EHR — until physicians start to lose their footing as they try to use the systems to accurately document patient care.  There are, however, a few precautions practice leaders can take to overcome this common stumbling-block. 

By Alok Prasad, RevenueXL

When medical group practices decide to implement or upgrade an electronic health records system, they often go full throttle throughout the process – that is until they hit a roadblock with clinical documentation. Even if physicians were on board before go live, once the technology has been implemented, they often complain that documentation in the application takes too long, or it’s too burdensome of a process to take on with their patient load.

But no matter how expensive or fancy an EHR is, without clear, accurate, populated documentation, the technology can never help deliver the clinical care and operational benefits that many group practices expect from it. And now that the integrity of patient data within EHRs is required for participation in the Centers for Medicare and Medicaid Services’ (CMS) and other payers’ financial incentive programs, accurate documentation by physicians and other staff is extremely imperative to nearly all aspects of any practice.

There are, however, a few things that practice leaders can do to avoid and overcome the documentation derail before and after they go live with an EHR.

Choosing the Right Technology – Templates or Free Text
When analyzing EHR options, it is important to ensure that the technology enables physicians to truly “tell the clinical story” — and to do so efficiently. Remember, each and every patient has a unique clinical story. As such, the EHR must enable the physician to recount the particulars of each patient’s situation in great detail and with great efficiency.

To support this dual objective, practice leaders should understand their providers’ approach to documentation. They should develop a specific, thorough and comprehensive approach to data input for their practice that is based on these documentation preferences.  Then, they need to find an EHR that can fully accommodate these preferences – while also enabling speedy and accurate clinical documentation.

Implementing technology that is not up to snuff is likely to result in frustration. According to “Electronic Health Record Use a Bitter Pill for Many Physicians,” a report published in Perspectives in Health Information Management, clinicians often find and use “workarounds” when the technology does not mesh with their needs. For instance, when systems are awkward to use, physicians often choose to dismiss the EHR during the patient encounter and instead complete required documentation sometime after treating the patient. In such situations, physicians often take notes on paper during the patient visit and then rely on this information to complete EHR data entry later. Such workarounds could actually make EHRs less efficient – and add to physician workload.1

To avoid such frustrations, however, the EHR technology needs to meet provider’s needs while also enabling complete accurate documentation in an efficient manner. Many EHR software solutions provide pre-defined templates that can only be changed by the vendor or IT personnel. The idea behind these templates is that they enable physicians to quickly document clinical care. Other EMRs are template free, allowing physicians to tell the clinical story without using the various check-lists and boxes found on templates. These allow physicians to tell each patient’s story – without being limited to certain pre-conceived notions.

Incorporate the Best of Both Worlds

For many practices, however, the best option incorporates the best of both worlds: it makes it possible for physicians to use free text to create patient narratives but also enables them to use common problem templates. With EMRs such as the one available from RevenueXL, physicians use predefined templates or forms to document very common and repetitive procedures and visits and to speed up their documentation efforts. And, they use free text to ensure that the particulars of individual patient stories are properly documented.

When evaluating a potential new system, leaders should learn and test its capabilities, including how all of its documentation templates work to ensure they purchase an application that matches how they want to structure their new documentation approach.2

Scenario Testing or Walkthrough is Vital to Succeed

Practice leaders also should create scenarios that are common to their specific practice and evaluate how the technology would be used to fully document them. For example, for documenting a new patient, the practice should review various parameters in each system they are evaluating including:

  • How many steps are required to establish a new patient record?
  • Is the process straightforward?
  • Does it accommodate non clinicians who might be entering the information?
  • Do the screens flow logically?
  • Can they add additional information later?
  • How are outside tests handled?3

Practice leaders also should evaluate how the potential EHR system would enable them to handle other scenarios. For example, some parameters they should evaluate in documenting a chronic patient recheck include:

  • How physicians would enter staff instructions for preparations to seeing the patient;
  • How easily they could access updated lab results;
  • How they would be able to change existing prescriptions;
  • And how they would develop a new treatment plan.

Taming the Templates
Once a practice has selected an EHR, they should further customize its documentation templates to best meet the practice’s goals. For example, they can rearrange the order of templates or dropdown lists, or assign non-physician staff to complete certain templates, such as demographic or vital information.

It is also important for an EMR to support template customization. Inflexible EMR templates can easily pull an otherwise viable practice under. With inflexible templates, doctors, nurses and specialists are forced to address patients in words that are not their own and may or may not apply directly to the situation at hand. Templates need to provide efficiency without straitjacketing the medical professional into a script that sounds completely unnatural and ill-suited for the task at hand. As such, EMR template customization should enable medical professionals to alter templates as much or as little as needed based on the patient’s unique situation.

While some of these customizable features may help practices encourage more expedited documentation from physicians, they also need to be careful that they aren’t erroneously causing inaccurate information within their patient records. This not only could result in incomplete patient data, but also signal an audit if they are participating in any financial incentive reimbursement programs.

Beware of Chart Notes Cloning
Medical groups need to specifically be careful about “whole-note cloning,” the practice of copying and pasting previous notes into the EMR in an effort to speed documentation.  While this documentation technique can increase efficiency, it also can threaten the trustworthiness of records. Indeed, copying and pasting allows physicians to easily incorporate lab tests, round the clock vitals, and every conceivable report in a single progress note. However, the practice can result in inaccurate documentation as well.  In fact, EMR cloning has resulted in Medicare and other insurance companies denying payments, thus inviting case review and new legal liabilities. Recent studies have also established EMR cloning as a potential factor in poor patient outcomes, such as when the cloning of glucose labs in hospitalized diabetics becomes harmful. As such, medical practices need to make sure that they are always documenting care so that it relays the particulars of the patient’s illness, with events sequenced chronologically, along with appropriately inserted clinical commentary and discussion of treatments.

Common documentation risks that can result from cloning include:

  • Vital signs that never change from visit to visit;
  • Information “copied and pasted” from a different patient’s record;
  • Documentation from another provider including their attestation statement;
  • And, identical verbiage used repeatedly for all patients seen by a provider for a specific timeframe with little or no modification regardless of the nature of the presenting problem or intensity of the service; at times, such verbiage includes contradictory indications (i.e., use of pronoun “he” instead of “she,” indication that patient has no pain when the documentation includes a record of pain)5

Use Modern Techniques to Streamline Documentation
Speech recognition is a feature that can help to streamline documentation efforts. With advancements in technology, it is possible for physicians to achieve 98%+ accuracy rate which is at par with the accuracy that is achieved by a human medical transcriptionist. Speech recognition is traditionally utilized to capture the historical portion of the medical health record since pre-designed templates cannot anticipate the full spectrum of facts presented by the patient.

Several EHR Systems that include the ‘handwriting recognition’ feature allow for data input via hand-written notes, input either directly or via a scanned or photographed page of information. In certain cases, it can facilitate easy and quick free text documentation.

Training, Training and More Training
Before going live on a new EHR — and documentation method — group practices should fully train everyone who will be using the system. Physicians, in addition to non-clinical providers, and support staff, should all understand not just how to use all the documentation templates, but who is responsible for doing so and how the practice wants go forward with various types of scenarios that may arise. Practices also might want to have super users who can be on site to help others after implementation.6

Beginning from day one of go live, practices should ensure that data is being entered properly — according to goals that had been previously agreed upon — and check randomly for consistency and efficacy of the documented protocols. They also should evaluate and retrain all users in three months, six months and a year after go live.

By selecting an EHR that supports unique clinical documentation preferences, streamlines documentation practices while allowing practices to completely tell each patient’s story, medical group practices can efficiently produce the clinical documentation that will enable them to provide quality clinical care, qualify for payments under government incentive programs and succeed under emerging value-based care payment models.


  • Meigs, S. Electronic Health Record Use a Bitter Pill for Many Physicians. Perspectives in Health Information Management, 2016 Winter. Accessed at:
  • Hertz. K. EHR Nightmare: Failure. MGMA Healthcare Consulting Group Blog. Accessed at:
  • HIMSS EMR Usability Evaluation Guide. Accessed at:
  • Cueva, J. EMR Cloning: A Bad Habit. Chicago Medical Society. Accessed at:
  • AHIMA. Integrity of the Healthcare Record: Best Practices for EHR Documentation, August 2013. Accessed at:
  • Hertz. K. EHR Nightmare: Failure. MGMA Healthcare Consulting Group Blog. Accessed at:

About The Author

Alok Prasad is the CEO of RevenueXL. For more information on RevenueXL’s EMR and EHR solutions, go to