Hardly any doctor expected a veritable flood of documentation requirements when choosing a career. Neither do you? Don't worry, neither am I. As a doctor, I've worked my hair out more than once when I heard the word “documentation requirement.” In this post, I'll tell you about my experience with the documentation requirement and everything you need to know about it. D'accord?
40 hours of overtime per month due to documentation requirements
I only realized how much the amount of documentation had changed my profession as a doctor when a patient asked me about it. Because he himself was frustrated that he had collected all his data up to four times (!) I had to write it down.
As a result, the patient's experience in hospital was negative. And mine too, of course. Like many other doctors at the beginning, I had completely misjudged everyday working life. A minimum of forty hours of overtime per month is a bitter reality. And this is primarily due to documentation requirements and not to patient treatments.
Caring for patients usually does not require much time: Discussion, examination and therapy planning take around 30-40 minutes. Operations are excluded from this. However, the documentation requires at least another 30-40 minutes. Completely exhausted, I asked myself the serious question over and over again whether I would really skip the evening to do paperwork.
It was therefore not uncommon for me to use the rest of the night to write patient letters. Because that was the only way I could avoid overtime on day work. Due to my exhaustion, the quality of the nightly documentation has unfortunately often left much to be desired.
Doctors document just under half of their working hours
In the daily medical bureaucracy, rehab applications were always a particular thorn in my side. Four pages of blank text, including all the patient's diagnoses and limitations. Handwritten Time required: 30 minutes
A study also confirms that this amount of time is unfortunately no exception. As a result, doctors spend every day around four hours of their working time with documentation. That is around 44 percent of the total working time! Almost all respondents state that the effort required for documentation and the required level of detail has increased.
Patient documentation creates risk of burnout
But what does everyday life look like apart from statistics? Visit with the whole team in the morning. Investigations are then requested, consultations written, doctor's letters prepared and clarifications carried out. An almost unmanageable paper jam that easily gets out of balance: When Mrs. Müller* has an allergic reaction or Mr. Bauer* needs a canned blood supply. Because that's when the actual medical profession is in demand. The price for the trip to applied medicine: Two hours of overtime and no lunch break.
The time that we doctors spend on documentation fluctuates so slightly and, in my case, is up to five hours a day. I have painfully noticed that patient contact is becoming more and more distant and that the end of work with the family is also being replaced by patient letters and surgical reports. Risk of burnout? Definitely
How to document correctly
The treatment contract obliges doctors to provide documentation. You can choose for yourself whether you want to document in electronic or paper form. Both are allowed. Make sure that the original content always remains recognizable; no information can be overwritten. Corrections can be dated.
The legal basis for the documentation requirement can be found in Section 630 f BGB of Patients' Rights Act. Unfortunately, there are no precise guidelines as to what exactly needs to be recorded. From a professional perspective, all current and future treatments and results must be documented. In particular, the anamnesis, diagnoses, findings, investigations including results, treatments/procedures and their effects, doctor's letters as well as consents and explanations. The language of the documentation should be in technical language and does not have to be understandable by laymen. Further information on documentation requirements can be found on the website of Association of Statutory Health Insurance Physicians Westphalia-Lippe.
How long is the retention period for patient data
According to Section 630 f BGB of the Patients' Rights Act, the patient data retention period is ten years from the end of treatment. However, civil compensation claims may be up to 30 years be used after treatment.
Process optimization makes documentation easier
In order to keep the documentation requirement as lean as possible, a clear distribution of tasks and outsourcing of as many administrative tasks of healthcare workers as possible helps.
In addition, documentation should be digitized right from the start. Paper shouldn't even be used in the first place. This is because it not only requires resources for production and disposal, but also for the physical storage of documents.
These tips and tricks make your job easier:
- By voice recorders and programs with voice recognition can save you a lot of time.
- When it comes to your documentation, introduce yourself to checklist. As a result, you forget less and feel more secure.
- By keeping an electronic patient record, you can always access previous examination results and anamnesis. As a result, representative doctors are also sufficiently informed about their patients.
- trainings For the entire team, the most common programs can reduce fears of contact with digitization.
Nelly helps you to minimize documentation requirements
Software solutions such as Nelly are one way to optimize processes: With Nelly, you can make patient admissions completely paperless and thus save a lot of time. Use digitization so that the documentation requirement doesn't rob you of any time for your actual job. Not only do we doctors benefit from this, but also patients and our families. We advise you non-binding and free to your individual case!
*names made up freely by the editors.
The personal names used in this article always refer equally to all persons. Dual naming and alternate names are omitted in order to improve readability.
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