Key technology features to support point-of-care documentation

Studies have shown that point-of-care documentation improves the accuracy of the patient record. When the clinician is charting in real time rather than after hours, information can be shared promptly, resulting in more coordinated delivery of care and clinicians experiencing better work-life balance. Supporting real-time documentation is essential in home health, where the staffing shortage is a persisting challenge, care is often disconnected, and reimbursement is increasingly more difficult.

In this blog, we explore critical features in an EHR to promote point-of-care charting and how it can benefit your organization.

Speech-to-text capabilities

We all talk faster than we type. That’s why voice-to-text capabilities can improve efficiency during a visit — as well as the quality of the documentation captured. More detailed narrative sections in the visit notes, communication notes, and clinical documents allow the clinician to paint a full picture of the patient and potentially reduce ADRs.

Embedded compliance support

To help ensure home health documentation supports the most up-to-date regulatory requirements, guidance incorporated directly within the workflow supports clinical decision-making. An internal OASIS scrubber offers clinicians real-time feedback about inaccuracies or inconsistencies within their OASIS assessment while providing clear direction to review and potentially correct their initial responses prior to submitting the visit to QA.

This key feature can also reduce the back and forth between the office and the field, improve the timeliness of OASIS submissions, and educate clinicians about the OASIS to help increase their accuracy on future assessments.

Supply vendor interface

When clinicians have the tools to complete supply ordering during patient care, demographics can automatically be sent to the supply vendor during the visit and upon delivery of supplies, information is automatically shared to billing. Clinicians no longer have to spend time ordering between visits or after hours and furnished supplies will auto-populate to the claim, supporting workflows for field and office staff.

Medication history import

Clinicians with real-time access to medication lists can efficiently verify what the patient is actively taking, upload that script directly into the patient record, and help eliminate the need for manual entry. This feature saves clinicians time and helps to improve the accuracy of the patient’s medication profile.

Interoperability features

Organizations should have the ability to receive and send documents electronically via messaging designed to be HIPAA-secure, eFax, and nationwide networks so clinicians have real-time access to documentation from prior care locations — both on- and offline. This connected approach allows providers to transition care effectively, develop plans of care accurately, and communicate critical concerns efficiently.