Patients can help with documentation

Save time with this medical record form

Would you like patients to help your staff document information on the medical record form? At South Jersey Health System in Bridgeton, NJ, a unique ED medical record form allows patients to start their records as part of the sign-in process, just as they would provide information in a physician’s office. 

The form was developed by a multidisciplinary group whose goals included:

  • having patients fill out sign-in information directly on the triage sheet;
  • streamlining patient and paper flow from entry point to discharge;
  • increasing patient participation in the care continuum and reducing redundant interview and history procedures;
  • avoiding duplicate documentation;
  • allowing documentation to flow according to the sequence of events in the patient’s visit.

At triage, the sign-in sheet instructs patients to fill out the top part of the form, which is placed nearby on the counter. That form becomes part of the medical record, says Michelle Regan Donovan, RN, BSN, president of Millennium Strategies, a health care consulting firm in Charlottesville, VA. Donovan helped develop the form.

The chart is placed in a designated space intended to notify the triage nurse who might be seeing another patient, she says. "Even if she has received four or five of these sheets, the triage nurse now has sufficient basic information for a primary’ triage. That eliminates the verbal questioning of several patients who may have signed in on a sign-in sheet since her last check."

The triage nurse has the patient’s name with its proper spelling, a chief complaint in the patient’s own words, a phone number, and a family physician’s name, says Donovan. "The hospital now has the recorded time of entry and a home phone number for risk management should the patient leave the hospital prior to being seen," she adds.

The form also offers documentation prompts for items required for safe and lawful billing, claim assignments, and claim processing, she says. For example, the form includes prompts for physicians’ histories, physicals, and plan of care. "This reduces discrepancies in levels of examination and level of service fees billed out, which is a policy variant often cited in fraud and abuse investigation and prosecution," Donovan says.

Triage time is decreased

Because full assessments are not completed in the triage area, the time a patient spends in triage is decreased, says Sandra Dietrich, RN, MSN, director of nursing for emergency services at South Jersey Health System Hospital. On average, the chart saves 10-15 minutes per patient, which improves overall patient flow, she says. "The physicians and nurses aren’t hunting all over the place for the patient’s chart and aren’t waiting for each other to complete their documentation."

Previously, patients had to be asked for all information verbally, including their names and times of arrival, she says. "As long as it’s legible, we can go right past that, so it saves time." 

Patients used to sign a sheet when they arrived, but they only included their names and the arrival times because the chief complaint could be determined by others, says Donovan. "This created an inefficient process since the triage nurse still needs a chief complaint if she is to sort more than a single patient," she explains.

The form allows the triage nurse to get more information instead of just a name and time recorded on a publicly accessed sign-in sheet. "Joint Commission [on Accreditation of Healthcare Organizations] standards on patient confidentiality disallow the documentation of chief complaint on the sign-in sheet since other patients have access to same," she explains.

The form also reduces the liability and workload of the triage nurse when several patients appear at one time for triage with unknown reasons for visiting, Donovan says. "When the triage nurse has access to multiple charts initiated by the patient, she is able to review these for determining the order of triage processing," she explains.

At St. Vincent’s Medical Center in Jacksonville, FL, a patient medical profile form saves about 10 minutes on complicated patients with involved histories and two to three minutes on less complicated patients, says Ralph Badanowski, MD, FACEP, the ED’s medical director. "The doctor, nurse, or physician’s assistant can do a focused history using the profile as a guide," he says. 

The staff would have to obtain this history anyway to complete the necessary documentation and provide appropriate care, Badanowski notes. "This saves time, because the forms are filled out in the waiting room or registration while the patient is being processed."