Physician Time Documentation Requirements

Medical professionals do not only have to put a lot of hours into their practice but also have to spend additional time fulfilling a variety of regulatory requirements by filling out all sorts of documentation. While these requirements can put a lot of strain on these practitioners, physicians can speed along documentation with various technological innovations.

Medical School Documentation

• Medical school residents receive training from teaching physicians. These teaching physicians must document their presence and the time spent participating in the clinical services on behalf of the patients. The services that the teaching physician must document include acute care provided for chronic illnesses. The physician must document why the care provided was reasonable and necessary and must point out that the physician did not have other responsibilities when performing the medical services.

Critical Care

• Critical care is a time-based documentation. Physicians must note the total time spent evaluating, managing and providing critical care to the patient. The physician does not document time spent on billable procedures. During the documented critical care services, the physician must have been immediately available to the patient.

Time Pressures

• Physicians must accurately document their activities and the services they provide. They also must provide very fast services to allow them to see enough patients to keep their medical practices in business and to keep costs down for patients. However, these consistent documentation requirements slow down the rate at which the physician can perform work.

Technology Integration

• According to Webmedx, a clinical documentation services provider, physicians can speak up to 400 percent faster than they can type. Fortunately, technology exists that converts spoken language into text, which medical writers can then edit for clarity. This technology helps physicians meet the requirement for documentation without reducing work productivity. However, to effectively incorporate these technologies, the physicians must have basic computer skills, which can take time for the physicians to learn when they also must spend time keeping up to date with the latest medical research. When the physicians do not know how to use the technology, the technology can actually slow the physician down instead of the reverse. Fortunately, time-saving documentation technology has become increasingly easier to use, especially as software developers have entered into dialogues with physicians regarding how the technology can more effectively integrate with the daily goings on of the medical environment. Yet, as technology advances more rapidly, hospitals must continually incorporate improved technology to remain competitive. While some of these technologies cost a lot to incorporate, other technologies are free.

Signing

• Physicians must countersign, re-date and re-time hospital orders within 24 hours. Hospitals that do not comply with documentation rules can lose their accreditation. Physicians who do not comply with these rules can lose their hospital privileges as a penalty for putting the hospital at risk for losing its accreditation status.