Team Documentation

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Learning Objectives

Describe how to design and implement a team documentation process
Identify documentation assistants and train them in team documentation
Describe ways to optimize the workflow after implementation

Introduction

Electronic health record (EHR) systems are a fundamental part of modern-day medicine, but many physicians dislike how the documentation takes away from their time with patients. Implementing team documentation can help to improve documentation efficiency (and reduce redundancy), provide better care to patients, and reduce physician burnout.¹^,2

What Is Team Documentation?

Quiz Ref IDTeam documentation, or multiple contributor documentation, is a process where nonphysician team members assist with documenting visit notes, entering orders and referrals, reconciling medications, and preparing prescriptions during a patient visit.¹^,2 Clinical team members, such as medical assistants or nurses, or nonclinical team members, such as dedicated scribes, can support team documentation. The degree of task-sharing varies according to state and local scope of practice regulations. Still, overall, this process improves patient-centered care because the physician is less focused on EHR documentation and more present during the visit.

Decreasing physician time spent on documentation tasks that other team members can handle is also an important cost-saving tool for organizations.

How Much Time and Money Can Team Documentation Save My Practice?

Use this calculator to estimate the amount of time and money you could save by implementing team documentation in your practice. Enter the amount of time spent on documentation activities by physicians per day that hiring a documentation specialist could eliminate. The result will be the savings of implementing team documentation in your practice. Results may vary by practice. Calculations are for demonstration purposes only. Actual savings may vary.

Q&A

Which parts of a visit note can a nonphysician documentation assistant write as part of a team documentation process?
Under Medicare payment rules for new and established office or outpatient E/M visits, a documentation assistant can enter:
- Chief complaint
- History of present illness (HPI)
- Past Family Social History (PFSH)
- Review of Systems (ROS)
- Medication list (eg, perform medication reconciliation)
The information does not need to be re-documented by the billing practitioner. Billing physicians simply review, update, and verify the information, sign, and date the note.
The physician must still personally perform the physical exam and medical decision-making activities of the E/M service being billed. For more information on the 2021 E/M CPT coding and documentation changes, please visit the AMA website on E/M coding here. The AMA's Debunking Regulatory Myths site also discusses this topic in depth.

Six STEPS to Implement Team Documentation

Create a Change Team
Decide Which Team Members Will Help With Documentation
Choose a Model
Define the Workflow
Start With a Pilot Team
Assess and Optimize

STEP 1 Create a Change Team

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

When creating a multi-disciplinary change team, select a high-level champion—the medical director, division head, or department chair—and include representatives from administration, nursing, medical assistants (MAs), information technology personnel, compliance, and physicians. It is helpful if all representatives agree on the goals, such as improved patient and clinician satisfaction, decreased physician burnout, and reduced pajama time spent on documentation.

STEP 2 Decide Which Team Members Will Help With Documentation

Quiz Ref IDThere are 2 categories of team members who can assist with documentation: clinical team members and non-clinical documentation assistants.

Clinical team members include:

Medical assistants (MAs)
Licensed practical nurses (LPNs)
Registered nurses (RNs)

Nonclinical documentation assistants include:

Students (pre-medical, pre-physical therapy, pre-pharmacy)
Transcriptionists or scribes (virtual options for these also exist)
Patients themselves (this is an evolving functionality of some EHRs where patients can participate in components of documentation, such as medication reconciliation or even entering aspects of the chief complaint or their history)

The scope of work will depend on the type of documentation assistant and model selected (see STEP 3).

Q&A

Can both clinical and nonclinical documentation assistants enter the same information?
Yes. Any documentation assistant, including clerical assistants or patients themselves, can enter elements of the visit note that do not determine the level of service but still warrant documentation for clinical purposes. These elements include:
- History of present illness
- Social history
- Family history
- Review of systems
- Medication list
- Physical exam
There are no restrictions on who can input this information into the patient's record.
For more information about who can document various aspects of visit notes, visit the AMA's Debunking Regulatory Myths overview of this topic.

STEP 3 Choose a Model

There are 2 different team documentation approaches based on whether the documentation assistant is a clinical or nonclinical person. When a clinical team member helps with documentation, the model is referred to as an advanced team-based care model; when a nonclinical team member is separately brought on, the model is referred to as a clerical documentation assistant (CDA) model.

The Advanced Team-Based Care Model

A specially-trained MA or nurse accompanies each patient from the beginning to the end of the appointment to provide team care services, such as health coaching, care coordination, and panel management. The nurse or MA assists the clinical documentation while the physician conducts their portion of the patient visit.

Typically, there are 2 to 3 nurses or MAs per physician, and they perform all of the clinical support functions and assist with the documentation.

Example: Cleveland Clinic
In the family medicine practice of Kevin Hopkins, MD, at the Cleveland Clinic, trained nurses and MAs follow a 3-step process. There are 2 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 during rooming to guide the recording of the initial history. 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 they discussed with the patient.
- Visit: The MA and physician enter the exam room together. The physician confirms and expands on the preliminary history and examines the patient while the MA documents in real-time. The physician then diagnoses 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 advanced rooming and discharged protocols toolkit.

Access [Pre-Visit Questionnaire].

Access [Visit Planner Checklist: Order Sheet for Patient Visits].

Access [Health Maintenance Checklist].

These Success Stories provide examples of how others created and implemented team documentation processes using clinical team members, including certified and/or specially trained medical assistants as documentation assistants:

The AMA STEPS Forward™ Podcast Series

LISTEN NOW: Hear Elizabeth Stambaugh, MD, talk about her work at Wake Forest Health Network on the AMA STEPS Forward podcast.

Find other AMA STEPS Forward podcasts: https://edhub.ama-assn.org/steps-forward/pages/podcast.

The Clerical Documentation Assistant Model

The clerical documentation assistant (CDA) accompanies the physician during each patient visit and only records the encounter. There is typically 1 CDA per physician. Other team members, such as nurses, MAs, or physicians, are responsible for the clinical aspects of care. This includes obtaining vital signs, performing medication reconciliation, or providing patient education.

Example: University of California, Los Angeles
Nonclinical team members 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 physician's direction, the P²s enter all aspects of the patient encounter into the EHR, including the patient history, physical exam findings that the physician verbalizes, procedures, and clinic charges. They also queue orders 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 stay 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 patient visit, they complete the encounter in the EHR and send the documentation to the physician for review. This approach saves considerable time. In this practice, there are 3 P²s for every 2 physicians. This 3:2 ratio allows continuous rotation of P²s in the clinic to minimize interruptions in the workflow.

These Success Stories provide examples of how others created and implemented team documentation processes using nonclinical team members, such as care team coordinators or outsourced scribes as documentation assistants:

Q&A

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 find they do not need to alter the size or configuration of existing exam rooms.
How do you position the documentation assistant in the exam room so they are unobtrusive?
Sometimes, people express concern that another person in the room interferes with the patient-physician relationship. However, the extra person may actually improve the patient-physician relationship because the physician can provide full attention to the patient and is not distracted by data entry.³ When employing an advanced team-based care model, the clinical team member helps interact with the patient during the visit and does not need to “disappear.”⁴
In one practice, the nurse who helps with recording the encounter and physician positions themselves according to the patient's care needs. When the patient is seated at the desk, the physician is also at the desk while the nurse stands at the counter. When the patient is on the exam table, the physician stands beside them, and the nurse moves to the desk. The interaction with the patient determines the subtle choreography in the room.⁴
The positioning also depends on the practice's technology infrastructure and hardware. Some practices use tablets to improve mobility, but this approach can also be taken with laptops or desktop computers.⁴
How do patients feel discussing personal or private issues with the documentation assistant in the room?
Most patients are open to an additional medical professional helping with their visit. Some patients even welcome having another person in the room, especially if the physician explains that the documentation assistant's role is to ensure accurate documentation and handle computer tasks so the physician can focus on them.³^,4
Reassure patients when you introduce the team care process that they have the option of being alone with the physician. In addition, the physician can “read the room” and if they sense that the patient is uncomfortable for any reason, they may signal to the documentation assistant to step outside. Documentation assistants may also excuse themselves during sensitive parts of a visit. Exam rooms fitted with curtains or screens could provide additional patient privacy while the documentation assistant remains in the room.⁴

STEP 4 Define the 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 enable the record to be “passed” from one user to another without being closed. Choreograph the work and expect to refine it with experience.

Other items for consideration:

Which devices will the assistant and physician use?
Will template notes be used?
Will documentation assistants be responsible for entering orders?
How will the physician sign the team notes and orders?

For more tips and tricks to tailor your EHR to meet your needs and optimize workflows, see the AMA STEPS Forward™ Taming the EHR Playbook.

Q&A

How much of the documentation should documentation assistants be responsible for?
The role played varies according to specialty and physician preference. In some practices, the documentation assistant records the majority of the patient's medical history, exam, diagnoses, and plan of care as indicated by the physician. In others, the documentation assistant records portions of the patient's medical history, exam, and administrative data only. 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 closing the patient's visit.
How do I train existing team members to implement the team documentation process in my practice?
The Joint Commission lists the following education and training requirements as the minimum competencies for documentation assistants:
- Medical terminology
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Principles of billing, coding, and reimbursement
- EHR navigation and functionality, as appropriate based on job description
- Computerized order entry, clinical decision support and reminders, and proper methods for placing or pending orders
Quiz Ref IDSome physician practices contract companies that train medical documentation specialists. Others train their teams internally. While the second option is a considerable time investment, the team will learn exactly what they need in their specific practice environment. The Cleveland Clinic family practice department developed an internal medical assistant training program; details can be found here. Find more resources on medical assistant training in the Medical Assistant Recruitment and Retention toolkit.
Importantly, no matter how the practice initially accomplished training, it should be 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.
Can a documentation assistant enter orders dictated by a physician during a visit?
According to the Joint Commission, any licensed, certified, or unlicensed team member, including registered nurses, licensed practical nurses, medical assistants, and clerical personnel, may enter orders at the direction of a physician.
Team members who are not authorized to “submit” orders should leave the order as “pending” for a certified or licensed team member to activate or submit after verification. The authority to pend vs activate or submit orders varies based on state, local, and professional regulations. In either case, the use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. The Joint Commission does not consider orders transcribed into the EHR to be verbal orders.
While the Centers for Medicare & Medicaid Services (CMS) is silent on who may enter orders, in general, CMS considers diagnostic test order requirements met if there is an authenticated medical record by a physician supporting their intent to order the tests. Again, this may vary by state, local, and professional regulations.

Figure 1. Sample Team Documentation Workflow

STEP 5 Start With a Pilot Team

Developing collaborative care is hard work. It is best to start small. We suggest a pilot with 1 or 2 physicians. The pilot 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. As institutional knowledge grows and bugs are worked out, the process can be spread to more physicians. Many practices report a 3- to 6-month learning curve.

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

Q&A

How do I select which physicians should be part of the pilot?
The physician should be willing to “let go” of a certain amount of control of their notes and documentation style, invest in training team members, and learn a new model. In return, they will have the opportunity to be a change agent for the organization and be among the first to have help with the burden of documentation.
What should I look for in documentation assistants?
Essential qualities to look for in a documentation assistant include being personable and able to put patients at ease. Essential skills include being able to elicit the preliminary history, have good keyboarding abilities, and being able to navigate the EHR. A minimum typing competency and timed typing test could help you ascertain the level of skill with keyboarding. Individuals may be better able to document the visit if they also have an understanding of billing requirements.⁴

STEP 6 Assess and Optimize

Quiz Ref IDTraining is ongoing. Weekly meetings allow the physician and team to remain current with the happenings in the practice, any barriers to care, and updates to the process. 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 and clinical issues, billing, and coding.

Access [Team Documentation Implementation Checklist].

Access [Measure the Impact of Team Documentation].

Q&A

What errors, if any, should I anticipate with a new documentation assistant?
Training and the working relationship between the physician and the documentation assistant can impact documentation accuracy and completeness.⁴ Establishing a close working relationship and training on medical terminology, billing, and other practice specifics can help reduce errors.
Keep in mind that documentation might be more accurate because the documentation assistant is focused on that task while the physician focuses on providing care. In addition, because documentation occurs in real-time, there are fewer opportunities for details to be misremembered or confused between patients.⁴
For some teams a hybrid approach works best. In a hybrid approach the documentation assistant does most of the documentation, especially those elements that are structured text entries, whereas the physician types or dictates any explanation behind the medical thinking or more complicated aspects of the care plan.⁴

Conclusion

Team documentation instills a sense of cooperation among care team members 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.

AMA Pearls

With proper training, both clinical and nonclinical documentation assistants can perform the same documentation duties.

Team documentation instills a sense of cooperation and empowerment among care team members, resulting in greater professional satisfaction.

Team documentation enhances the patient-physician relationship by allowing the physician to focus more on the face-to-face patient interaction and providing care.

Resources

Pre-Visit Questionnaire

(53 KB)

Visit Planner Checklist: Order Sheet for Patient Visits

(49 KB)

Health Maintenance Checklist

(51 KB)

Team Documentation: Implementation Checklist

(47 KB)

Measure the Impact of Team Documentation

(109 KB)

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

If applicable, all relevant financial relationships have been mitigated.

Credit Renewal Dates: October 23, 2017; February 2, 2018; April 25, 2019; April 21, 2022

Disclosure Statement: 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.

Disclaimer: AMA STEPS Forward™ content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward™ content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward™ content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward™ content.

About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group is committed to making the patient–physician relationship more valued than paperwork, technology an asset and not a burden, and physician burnout a thing of the past. We are focused on improving—and setting a positive future path for—the operational, financial, and technological aspects of a physician's practice. To learn more, visit https://www.ama-assn.org/practice-management.

References:

Sinsky CA, Bodenheimer T. Powering-up primary care teams: advanced team care with in-room support. Ann Fam Med. 2019;17(4):367–371. doi:10.1370/afm.2422 Google Scholar

Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15(7):35–40. https://www.aafp.org/fpm/2008/0700/p35.html Google Scholar

Yan C, Rose S, Rothberg MB, Mercer MB, Goodman K, Misra-Hebert AD. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016;31(9):990–995. doi:10.1007/s11606-016-3719-x Google Scholar

Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23–29. https://www.aafp.org/fpm/2014/1100/p23.html Google Scholar

Disclaimer: AMA STEPS Forward^® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward^® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward^® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward^® content.

Team DocumentationImprove Efficiency of EHR Documentation

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The AMA STEPS Forward™ Podcast Series

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AMA Pearls

Resources