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Quiz

Team DocumentationImprove Efficiency, Workflow, and Patient Care

Developed in collaboration with

Learning Objectives
1. List steps to effectively implement the team documentation process
2. Explain how to design an efficient documentation workflow
3. Identify methods to appropriately delegate administrative tasks to various staff
4. Describe ways to manage process improvements after implementing the team documentation process

0.5 Credit CME

AMA STEPS Forward

October 23, 2014

Team-Based Learning

Activity Information and Disclosures

Christine A. Sinsky, MD, FACP^a

Author Affiliations

^aVice President, Professional Satisfaction, American Medical Association

Module Take Quiz Resources

How will this module help me successfully put team documentation in place?

Describes eight steps to select a team documentation model, train staff, and continuously improve the process.
Provides answers to common questions about team documentation.
Shares advice on situations your practice may encounter during implementation.
Includes case reports describing how practices are using team documentation.

Introduction

Electronic health record (EHR) systems can be beneficial, but the chief complaint for many physicians is that it takes away from their time with the patient. However, implementing team documentation can help to provide better care to patients, reduce physician burnout, and improve practice efficiency.

What is team documentation?

Quiz Ref IDTeam documentation, also referred to as “scribing,” is a process where other team members assist with documenting visit notes, entering orders and referrals, and preparing prescriptions, during a patient visit. This process improves patient centered care as the physician is less focused on EHR documentation, and can have a more meaningful interaction with the patient.

Q&A

Under Medicare payment rules, can non-physician staff, such as a registered nurse (RN), licensed practical nurse (LPN), or medical assistant (MA), enter elements of an evaluation and management (E/M) visit?
In both the 2019 Fiscal Year Medicare Physician Fee Schedule and an FAQ dated Nov. 26, 2018, CMS expanded current documentation policy applicable to office/outpatient E/M visits. Starting Jan. 1, 2019, any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the patient does not need to be re-documented by the billing practitioner.
Instead, when the information is already documented, billing practitioners can review the information, update or supplement it as necessary, and indicate in the medical record that they have done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (HPI, Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits.
CMS notes that it has never addressed who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
The physician must still personally perform the physical exam and medical decision-making activities of the E/M service being billed.
For additional information, please visit AMA's Debunking Regulatory Myths site, which discusses this topic in depth.

Interactive Calculator: Team Documentation

Use this calculator to estimate the amount of time and money you could save by implementing pre-visit laboratory testing in your practice. Results should be verified for your specific practice and workflows.

Enter the amount of time per day spent by physicians on documentation activities that could be eliminated by hiring a documentation specialist. The result will be the savings of implementing team documentation in your practice. Results may vary by practice.

Interactive

Calculate your savings

Eight STEPS to implement team documentation:

Create a change team.
Decide who will help with team documentation.
Determine the model: Clerical documentation assistant (CDA) or advanced team-based care.
Quiz Ref IDStart with a pilot.
Select the pilot personnel based on commitment.
Define your workflow.
Start small.
Meet weekly.

Step 1 Create a change team.

You can't make a big change in your practice without help. A change team is a small group of team members who will identify barriers and determine the best manner to implement changes designed to improve the new process, such as team documentation.

When creating a change team, select a high-level champion – such as the medical director, division head, or chair of the department— and develop a multi-disciplinary team, including representatives from administration, nurses, medical assistants (MAs), information technology personnel, compliance, and physicians. It is helpful if all representatives agree on the goals, such as improved patient and provider satisfaction, better quality, and improved productivity.

Step 2 Decide who will help with team documentation.

Decide if the individuals performing the documentation will be an MA, a nurse, a pre-med student, pre-physical therapy or pre-pharmacy student, a former transcriptionist or a dedicated scribe. The type of assistant will determine the scope of work.

Q&A

Under Medicare payment rules, can an RN document a patient's medication list in the EHR as part of medication reconciliation (MR) during E/M visit?
Yes, where MR is part of the ROS or PFSH for the E/M service, under Medicare payment rules, the medication list may be recorded by any ancillary staff, and then signed by the physician. MR is included in the Advancing Care Information performance category in the Merit-Based Incentive Payment System (MIPS) as well as the Meaningful Use (MU) program.
Can licensed staff enter electronic orders, such as laboratory or x-ray requests?
Yes, certain credentialed individuals may enter orders for diagnostic tests in an office (non-facility) setting. Medicare generally requires that services provided/ordered be authenticated by the author. A physician's failure to properly authenticate an order could lead to denial of payment by a Medicare Administrative Contractor (MAC).
However, there are circumstances where Medicare does not require a physician signature, such as for diagnostic tests (e.g., clinical diagnostic laboratory tests and diagnostic x-rays), when ordered in an office setting. While these orders need not be signed by the physician, he or she must clearly document in the medical record his or her intent that the test be performed. Providers should also check state, local, and professional guidelines.

Step 3 Determine the model: Clerical documentation assistant (CDA) or advanced team-based care.

The clerical documentation assistant CDA Model:

The clerical documentation assistant accompanies the physician during each patient visit and assists only with record-keeping. Separate team members, such as nurses, MAs, or the physicians are responsible for the clinical aspects of care. This includes obtaining vital signs, performing medication reconciliation, or providing patient education. There is typically one CDA per physician. In addition, the practice employs MAs and nurses to perform the clinical support functions.

Example: University of California Los Angeles
Non-clinical staff in the geriatric practice at the University of California, Los Angeles, serve as Physician Partners (P²s). The P²s document aspects of the office visit, facilitate the flow of patients through the office, and improve the efficiency of ordering and/or scheduling tests and medications.
Under the direction of the physician, the P²s enter all aspects of the patient encounter into the EHR, including the patient history, physical exam findings that are verbalized by the physician, procedures and clinic charges. They also queue orders that were discussed during the visit for the physician to sign.
At the close of the visit when the physician leaves the room to see the next patient, the P²s stays behind to review the after-visit summary with the patient, conduct any needed care coordination with other team members, and provide patient education. If labs are required, the P²s may also escort the patient to improve patient flow through the clinic. After the P²s conclude the visit with the patient, they complete the encounter in the EHR, and the documentation is sent to the physician for review. With this approach, the physician only needs to review and sign documentation and queued orders, saving significant time. In this practice, there are three P²s to every two physicians. This 3:2 ratio minimizes interruptions in the workflow by allowing continuous rotation of P²s in the clinic.

Advanced team-based care model:

A specially-trained nurse or MA accompanies each patient from the beginning to the end of the appointment to provide team care services, such as health coaching, care coordination, and in-reach approach to panel management. In addition, the nurse or MA assists with the clinical documentation while the physician conducts his or her portion of the patient visit.

Typically, there are two to three nurses or MAs per physician and they perform all of the clinical support functions in addition to assisting with the documentation.

Example: Cleveland Clinic

In the family medicine practice of Kevin Hopkins, MD, at the Cleveland Clinic, trained nurses and/or medical assistants follow a three-step process. There are two MAs per physician.

Pre-visit: The physician and team design protocols and templates for specific patient complaints and chronic conditions common to the practice. The MA uses these tools to guide the initial history recorded during rooming. During this step, the MA also updates the past medical, social, and family histories, reviews and sets up orders for any health maintenance items that are due, and reviews the patient's medication list and refills. The MA then exits the room and huddles with the physician to share what was discussed.
Visit: The MA and physician enter the exam room together. The physician confirms and expands on the preliminary history and examines the patient, which the MA documents in real-time. The physician then makes a diagnosis and crafts a treatment plan with the patient. The MA continues to record the assessment and treatment plan and queues any orders for the physician's signature. The patient asks any further questions and the physician moves on to the next patient.
Post-visit: The MA remains with the patient to reinforce the treatment plan, provides an updated medication list and visit summary, engages in motivational interviewing, and provides self-management support. The MA then assists with appointment and referral scheduling.

Learn more about the expanded nurse and MA role in the expanded rooming and discharge protocols module.

Q&A

Who should assist with documentation?
The team member who assists with medical documentation varies across practices and specialties. Quiz Ref IDThe model may include clinically trained staff (e.g., MAs, LPNs, RNs, physical trainers, ophthalmology technicians, PAs, and NPs) who can conduct elements of the patient visit themselves. The degree of task-sharing varies according to state and local scope of practice regulations, which may include:
- Taking visit notes.
- Submitting prescription requests and/or renewals.
- Entering laboratory test orders.
- Administering immunizations.
- Providing patients with supplemental health coaching.
Alternatively, the model may include non-clinically trained staff, for whom the term “clerical documentation assistant” (CDA) can be used rather than “scribe.”
Will I need more space in the exam room to implement this process?
The size of the exam room is important. There needs to be enough space for the patient, one or more caregivers or family members, the physician, and the CDA, nurse or MA. However, most practices may find they do not need to alter the size or configuration of existing exam rooms.

Step 4 Start with a pilot.

Developing collaborative care is hard work. It is best to start small. We suggest a pilot of one or two physicians. As institutional knowledge grows and bugs are worked out, the process can be spread to more physicians. Many practices report a three-to six-month learning curve.

Sometimes, people express concern that another person in the room interferes with the patient-physician relationship. However, we find that the extra person actually improves the patient-physician relationship because the physician is able to provide full attention to the patient and is not distracted by data entry.

Q&A

How do you position assistants in the exam room so they aren't intrusive?*
In an advanced team-based care model, the assistant helps interact with the patient during the visit and does not need to “disappear”.
In one practice, the nurse and physician position themselves according to the care needs of the patient. When the patient is seated at the desk, the physician is also at the desk, and the nurse stands at the counter. When the patient is on the exam table, the physician stands beside the patient and the nurse is at the desk. There is subtle choreography and the providers switch places automatically, depending on how they need to interact with the patient.
Positioning also depends on the available technology infrastructure and hardware. Some practices use tablets for better mobility, but this can certainly be done with laptops or desktop computers as well.

Step 5 Select the pilot personnel based on commitment.

The physician should be willing to invest in training the staff and learning a new model. The team should be enthusiastic about assuming new responsibilities and being trailblazers within the organization. They should also be eager to help shape the new process. Look to nurses and MAs to help along the way.

Q&A

What qualities or skills should I look for in an assistant in the team care model?*
The most important skills are being personable, putting the patient at ease, and eliciting the preliminary history. It is also important to have good keyboarding and EHR-navigating skills. A minimum typing competency and timed typing test may be a good idea. An understanding of billing requirements also helps individuals document accurately.
Does the assistant perform all of the medical recordkeeping duties or do physicians still play a role?
This varies according to specialty and physician preference. In some practices, the assistant records the majority of the patient's medical history, exam, diagnoses, and plan of care as indicated by the physician. In others, the assistant records portions of the patient's medical history, exam, and administrative data. The physician may document key elements of the patient's medical history and medical decisions. In each example, the physician reviews and signs off on the medical record before the patient's visit is closed.

Step 6 Define your workflow.

Identify who will perform which responsibilities during each patient visit.

Don't forget to consider your EHR features and functionality as well. Some EHRs allow only one user in the record at a time. Others allow the record to be “passed” from one user to another without being closed. Choreograph the work and expect that it will be refined with experience.

Other items for consideration:

Will template notes be used?

How will the provider sign the team notes and orders?

Determine which devices the assistant and physician will use. Will you use one computer or two? Will the computer be a laptop or a desktop?

Q&A

How do I train existing staff in my practice to implement the team documentation process?
Quiz Ref IDSome physician practices contract companies that train medical documentation specialists. Others train their own staff. While the second option is a considerable investment of time, the team will learn exactly what is needed as it pertains to the specific practice. In both examples, training is ongoing.
For instance, early in the implementation phase, the change team can consider debriefing daily to discuss what went well and identify opportunities for improvement. They can meet weekly for 30 to 60 minutes to review and adjust the workflow of the documentation process. They may also provide educational opportunities to learn more about clinical issues, billing, and coding.

Figure 1.

Sample Team Documentation Workflow

This workflow shows how team documentation can work in your practice

Step 7 Start small.

For the first few days, you might do team care for only half of your scheduled patients, or for all of your patients only a few days per week. Use the rolling start to refine the process and avoid change fatigue.

Q&A

Do patients mind discussing private issues with the assistant in the room?*
We have found that if the physician explains that the assistant's role is to ensure accurate documentation and handling the computer so the physician can remain focused on the patient, most patients accept and welcome the additional medical professional helping with their visit. Many patients even see it as an opportunity to have another advocate for their health care.
When introducing the team care process, it may be reassuring to let patients know that it is no problem if they want to be alone with their physician. In addition, if the physician or assistant senses that the patient is uncomfortable—such as during certain sensitive parts of the visit—the assistant may leave the room. Exam rooms may also be fitted with curtains or screens that can provide additional patient privacy.

Step 8 Meet weekly.

Quiz Ref IDTraining is ongoing. The physician and team should meet at least weekly for 30 to 60 minutes to review and adjust the workflow. The meetings can also be used to continue the educational process about clinical issues, billing, and coding. Weekly meetings allow the physician and team to remain up-to-date with what is going on in the practice, any barriers to care, and updates to the process.

Q&A

Is using an assistant more likely to result in documentation errors than doing it yourself?*
Accuracy and completeness of the documentation depends on training and a close working relationship between the physician and the assistant. In some ways, the documentation is likely to be more accurate because the assistant is focused on documentation while the physician is focused on providing care. In addition, the documentation is done in real-time, so there are fewer chances for details to be misremembered or confused between different patients.
Some teams adopt a hybrid approach where the assistant does most of the documentation, especially those elements that are most suited to structured text entries, while the physician types or dictates a few additional lines explaining the medical thinking and more complicated details of the care plan.

Conclusion

Both the clerical documentation assistant model and the advanced team-based care model benefit the practice as a whole. Team documentation instills a sense of cooperation among staff at all levels of your practice, empowering them to take an active role in managing patient visits. Through ongoing training and weekly meetings, team documentation processes can evolve as your practice continues to grow.

Glossary

in-reach approachin-reach approach: Planning in advance so that gaps in care are closed at the time of each face-to-face visit.panel managementpanel management: A panel refers to the patient panel, or the patient population of the individual physician or practice. Panel management is managing the patient population by monitoring it for important preventive and chronic care based on guidelines set by the practice.

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Resources

Team documentation implementation checklist

(50 KB)

Team documentation metrics

(110 KB)

EHR Documentation FAQ

(40 KB)

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Target Audience: This activity is designed to meet the educational needs of practicing physicians,

*Disclaimer: Reprinted with permission from the journal Family Practice Management (2014). 21(6):23-29.

Those individuals marked with an asterisk below contributed towards Version 1 of this learning activity.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Planning Committee:

Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association*
Marie Brown, MD, MACP, Senior Physician Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center
Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association
Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association
Ashley C. Cummings, MBA, CRCR, CME Program Committee, American Medical Association
Kevin Heffernan, MA, CME Program Committee, American Medical Association*
Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*
Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*
Rhoby Tio, MPPA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability, American Medical Association*

Content Reviewers:

J. James Rohack, MD, FACC, FACP, Senior Advisor and former President, American Medical Association
Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center
Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association
David Eltrheim, MD, Family Physician, Mayo Clinic Health System–Red Cedar*
Michael Glasstetter, VP Advocacy Operations, Advocacy Planning & Management, American Medical Association*
Thomas Healy, JD, Vice President and Deputy General Counsel, American Medical Association*
Kevin D. Hopkins, MD, Family Medicine, Cleveland Clinic*
Michelle M. Johnson, RN, BSN, Patient Care Director, Caledonia Clinic, Mayo Clinic Health System*
Anton J. Kuzel, MD, MHPE, Chair, Department of Family Medicine and Population Health, Virginia Commonwealth University*
Jeffrey Panzer, MD, Medical Director, Oak Street Health*
Sara J. Pastoor, MD, MHA, Director, Primary Care Center, University of Texas Health Science Center at San Antonio*
David B. Reuben, MD, Archstone Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles*
Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*
Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*
Gordon Schectman, MD, MS, Primary Care Chief Consultant, Veterans Affairs Central Office*
Rhoby Tio, MPPA, AMA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability, American Medical Association*
Rachel Willard-Grace, MPH, Research Manager, Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California, San Francisco*

About the Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

ABMS MOC: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: February 2, 2018; April 25, 2019

References

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Team DocumentationImprove Efficiency, Workflow, and Patient Care

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Resources

Team Documentation Case Report: The Vancouver Clinic

Team Documentation Case Report: Cleveland Clinic

Team Documentation Case Report: Dr. Jim Ingram

Team Documentation Case Report: Via Christi Health

Working Smarter in Primary Care Means Transitioning to In-Room Physician Support

Success Story: Team Approach to Visit Documentation Saves Time

Success Story: Encounter Specialist Model Promotes Physician and Team Satisfaction

See More

Team DocumentationImprove Efficiency, Workflow, and Patient Care

Q&A

Q&A

Q&A

Q&A

Q&A

Q&A

Q&A

Q&A

Resources

Team Documentation Case Report: The Vancouver Clinic

Team Documentation Case Report: Cleveland Clinic

Team Documentation Case Report: Dr. Jim Ingram

Team Documentation Case Report: Via Christi Health

Working Smarter in Primary Care Means Transitioning to In-Room Physician Support

Success Story: Team Approach to Visit Documentation Saves Time

Success Story: Encounter Specialist Model Promotes Physician and Team Satisfaction

See More

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