Automatic Clinical Note Writing with Patient Intake

Patient intake is typically the first interaction between patients and providers. For every patient, whether a new or an existing patient, the provider’s office needs to capture certain details before the consultation.

Patients usually perceive this as an administrative burden. Also, most patients are anxious and maybe not in the state of mind to recall details and answer questionnaires while waiting to see the provider.

Despite these challenges, the importance of patient intake is unquestionable. Technological advances notwithstanding, the clinical adage compels that two-thirds of the diagnosis can be made just based on detailed patient history.1 A 2016 study by Johns Hopkins patient safety experts suggests that medical errors are the third leading cause of deaths in the US (over 250,000 deaths every year). This study has shed light on patient intake as a necessary and beneficial process for medical practices.

Moreover, a thorough patient intake paves the way for a significantly reduced documentation time per consultation.

So, how can providers reduce medical errors, minimise documentation burden, and comfort patients - while not missing any information?

The solution could be an easy-to-fill and efficient patient intake process. During the intake, the patient can enter her problems and give complete detail of her illness in digital forms before the consultation. As part of a provider’s EHR or a separate management system, patients can complete such patient intake forms before their appointment. This allows patients to share every bit of information (the smart intake ensures they do not miss anything) and also helps the providers to assess patients properly.

How does automating patient intake lead to pre-populated documentation?

The automated patient intake form takes care of every aspect of patient complaints. It elicits detailed responses and smoothly transits from one response to the next question. It usually starts with a patient booking an appointment for a consultation with the provider. With a confirmation message, a secure patient intake link is shared automatically with the patient who is asked to fill and submit all required details before an appointment.

Patient intake with complete information includes basic details like name, gender, age etc., presenting complaints, medical and family history, allergies, medications and a 14-point review of systems. Patients are also asked about their expectations from the visit. Let’s understand this in detail with an example:

A patient presents with complaints of headache. The patient intake system prompts all possible relevant questions with possible options like:

  1. In which part of the head do you feel the pain?
    • One side of the head
    • Around the forehead
    • In the back of the head
    • Or something else
  2. How long has it been going on?
  3. For how long does the headache last?
  4. Is it related to any specific cause?
  5. Medication History
  6. Past procedures/surgeries etc.

There are additional essential questions related to the complaint that will eventually help the provider to understand the illness and decide the treatment plan.

After the patient submits the data, a concise summary is presented to the provider prior to the consultation. Providers can assess patients’ health and prepare to address their expectations.

In follow up visits, providers can review charts and track progress in the treatment plan.

How does smart patient intake help in care delivery?

A thorough patient intake can improve healthcare at every step. A 2018 report by KLAS (research and insights firm), titled, ‘Patient Intake Management 2018: Solutions for a More Efficient Practice’, emphasises the benefits of automated patient intake process in eliminating duplicative and unnecessary paperwork, raising patient satisfaction and boosting financial parameters.

Let’s see how it helps:

Providers’ Benefits

  1. Comprehensively captured clinical details: In contrast to static intake forms, a smart intake can adaptively probe into presenting symptoms. Patient responses drive the questioning deeper, as opposed to relying on patients to type out every detail, most of which they would not consider relevant.
  2. Reduced documentation burden: When a patient fills in a static intake form, the data provided in its unstructured free-text form cannot be used by providers for their documentation. A smart intake resolves this by processing patient responses and collating them into coded, billable clinical notes ready for providers’ review. This saves a great deal of time in insurance claims filing.
  3. Simplified patient assessment: In a static intake patient form, patients need to answer questions that may not even be related to their presenting complaints. This is greatly simplifies with a smart intake, where questions related to a patients’ complaints are presented first, followed by any other details required by the provider.
  4. Increased patient volume per provider: An automated patient intake saves providers upto 15 minutes per consultation. With this reclaimed time, providers can see more patients during each day, or simply spend quality time with family and friends.
  5. Increased revenue: With saved time and significant additional number of patients seen every day, the provider enjoys increased revenue with minimal effort on paperwork.
  6. Continuous and timely delivery of care: Patients can fill a smart intake at any moment of their choice during the day - at home, on the go or while waiting to see the provider.

Patients’ Benefits

  1. Detailed information shared with providers: Due to being anxious, distracted, or in a hurry, patients often forget mentioning critical details during the consultation. But when a smart intake elicits details from the patient when they are relaxed, this information is not missed.
  2. Patients contribute to their own health record: Patient-driven health-information is being seriously considered as a feasible solution to burnout caused by too much documentation. Empowering patients with the ability to document their own visit frees providers from constantly jotting down details for a meaningful and engaging consultation.
  3. Providers are well-informed about patient: A sense of comfort develops when the patient knows that the provider is already informed about her situation and must have a treatment plan ready to recommend to patients.
  4. More eye contact: An undisturbed eye contact is crucial for providers to engage patients meaningfully. With no scope of computer or notepad coming in between the patient and provider interaction, there is more eye contact and higher patient satisfaction.
  5. Higher acceptance rate of insurance claims: First-time acceptance rate of insurance claims is higher with coded, billable clinical notes from automated patient intake forms.

In conclusion, the care delivery process is considerably enhanced by an automated patient intake. It also raises the patient engagement strategy to the next level by reducing gaps in care. The process with automated clinical note becomes so streamlined that it reduces all hassles for a patient, provider as well as the healthcare staff.

References:

  1. NCBI Books - NBK349
  2. NCBI Article - PMC6614334