“Why do I have to include the vitals to my note if I currently documented them?”
” I purchased and documented a procedure; why does not the system understand the charge?”
As an Epic home builder, I hear a lot of complaints, like those above, from suppliers who need to know why a lot data entry is needed to justify billing.
I understand their frustration. But I likewise know Epic is capable of working smarter instead of making medical professionals work harder. As contractors, we must focus on making it easier to record and discover crucial details in the system.
Enhancing the Encounter Summary
One place to begin is the Encounter Summary report. With a little additional work, the Encounter Summary can replace the Progress Note as the source of reality for Coding and Compliance. Anything thats carried out in the encounter can be shown in the Encounter Summary without being contributed to the note (decreasing the dreadful “note bloat”).
For instance, we can include a complete surgical history print group, instantly, just like we put a SmartLink in the note. In the Encounter Summary, however, we can set it up so that the surgical history is just shown if someone clicked Mark as Reviewed– giving suppliers more control over whats in the documents, and providing Coding and Compliance more openness around what the companies did throughout the encounter. I call this “Dynamic Content.”
If we actually wish to get Providers to buy in, though, we cant stop with the Encounter Summary. Similar to the progress notes of the past, an Encounter Summary that reveals everything will be excessive to quickly examine for important information, and providers dont utilize their notes simply for billing and coding. We require to make sure they can quickly do 2 things: communicate their findings and evaluation paperwork from previous encounters.
Make Visit Information Easy to Review
The evaluation piece can be accomplished by either utilizing a various Encounter Summary for users and Coding and Compliance, or by including a couple of print groups to the Notes report in Chart Review. Depending on the specialized, you might also include some flowsheets or types completed in the encounter.
These choices make life much easier for suppliers, but its not possible without buy-in from Coding and Compliance. Decreasing note bloat also minimizes the danger of contrasting documentation; envision a new medication order that does not get included in the Progress Note because the SmartLinks arent refreshed prior to signing.
Simply like the progress notes of the past, an Encounter Summary that reveals everything will be too much to quickly evaluate for relevant information, and suppliers do not utilize their notes just for billing and coding. Reports can be attached to outgoing interactions, offering service providers the alternative to consist of the full Encounter Summary report or a more succinct Notes report. Lowering note bloat also decreases the risk of contrasting documentation; envision a new medication order that does not get consisted of in the Progress Note since the SmartLinks arent revitalized prior to finalizing.
With a little extra work, the Encounter Summary can change the Progress Note as the source of fact for Coding and Compliance. Anything thats done in the encounter can be displayed in the Encounter Summary without being added to the note (reducing the dreadful “note bloat”).
Over the last couple of years, Epic has made a lot of progress in streamlining documentation, making parts of the documents collapsible, and improving the layout of print groups. Now, its on us home builders to take advantage of whats offered. We can continue to strengthen the status quo– or we can make the system work smarter and lower threat while enhancing the lives of clients and users.
Communication is a little bit harder, however here we have the luxury of presenting multiple options. Reports can be connected to outbound interactions, offering providers the alternative to include the full Encounter Summary report or a more succinct Notes report. We can also produce a SmartList with different pieces of paperwork that a supplier can rapidly contribute to the text of the communication.
Owen Phelps is a qualified Senior Epic Consultant with 10+ years of experience, focusing on EpicCare Ambulatory build and optimization.