Doctor reports: This is how much time the documentation obligation takes
The jungle of documentation requirements has already tested your patience? You are not alone in this! All over the world, doctors spend hours every day dealing with bureaucracy. In this article, I share my experiences as a doctor and how you too can find time for your patients again.
The most important answers about the documentation obligation at a glance:
Einer Studie von Nuance Healthcare zufolge verbringen Ärzte etwa vier Stunden täglich mit der Dokumentation.
Laut § 630 f BGB des Patientenrechtsgesetzes, müssen Sie die Dokumentation bzw. die Patientenakte zehn Jahre aufbewahren. In Einzelfällen gilt eine Aufbewahrungsfrist von 30 Jahren.
Sie können Ihre Dokumentation sowohl in elektronischer- als auch in Papierform anlegen. Genaue Vorgaben, was konkret dokumentiert werden muss, gibt es leider nicht. Festgehalten werden müssen zum Beispiel: Anamnesen, Diagnosen, Befunde, Untersuchungen, Therapien, Eingriffe, Arztbriefe, Einwilligungen und Aufklärungen.
When choosing a career, hardly any doctor expected a veritable flood of documentation requirements. Didn't you either? Rest assured, neither did I. As a doctor, I have pulled my hair out more than once at the word "documentation obligation". In this article, I will tell you about my experiences with the documentation obligation and everything you need to know about it. D'accord?
40 overtime hours per month due to documentation requirements
I only realized how much the documentation effort had changed my job as a doctor when a patient asked me about it. He was frustrated himself that he had to write down all his data up to four times (!) during the surgical admission.
As a result, the patient's experience in the hospital was negatively tainted. And of course mine as well. I had completely misjudged the daily work routine, as many other doctors did at the beginning. A minimum of forty hours of overtime per month is a bitter reality. And that is mainly due to the documentation requirements and not to the patient treatments.
The care of patients usually does not require a lot of time: conversation, examination and planning of therapy take about 30-40 minutes. Operations are an exception to this. However, documentation requires at least another 30-40 minutes. Completely overtired, I asked myself every now and then the serious question of whether I was really skipping the end of the day to do paperwork.
So it was not uncommon for me to use the nightly rest to prepare patient letters. This was the only way I could avoid working overtime on daytime duties. Unfortunately, due to my overtiredness, the quality of the nighttime documentation often left much to be desired.
Doctors document just under half of their working time
In the daily medical bureaucracy, rehab applications were always a particular thorn in my side. Four pages of cloze text, with 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. According to this study, doctors spend around four hours of their working time on documentation every day. That is about 44 percent of the total working time! Almost all respondents state that the amount of time spent on documentation and the level of detail required has increased.
Patient documentation creates risk of burnout
But what does everyday life look like apart from the statistics? Morning rounds with the entire team. Afterwards, examinations are requested, consults are written, doctors' letters are written and clarifications are 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 blood unit. Because then the actual doctor's job is called for. The price for the excursion into applied medicine: two hours of overtime and no lunch break.
So easily the time we doctors spend on documentation fluctuates and in my case amounts to up to five hours a day. Painfully, I have noticed that patient contact is becoming more and more distant and that even after-work time with the family is being replaced by patient letters and OR reports. Danger of burnout? Definitely.
The documentation obligation: what you need to know
As annoying as detailed documentation is, it is also necessary. On the one hand, it serves patient safety, as a memory aid for healthcare staff, as information for treating colleagues and also for billing purposes.
How to document correctly
The treatment contract obliges physicians to document. You can choose whether you want to document in electronic or paper form. Both are permitted. Make sure that the original content always remains recognizable, no information may be overwritten. Corrections can be dated.
The legal basis for the documentation obligation can be found in Section 630 f BGB of the Patient Rights Act. Unfortunately, there are no precise specifications as to what exactly must be recorded. From a professional point of view, all current and future treatments and results must be documented. The anamneses, diagnoses, findings, examinations incl. results, therapies/interventions and their effects, doctors' letters as well as consents and explanations are particularly important. The language of the documentation should be in specialist language and does not have to be understandable for laypersons. For more information on the documentation requirement, please visit the website of the Kassenärztliche Vereinigung Westfalen-Lippe (Association of Statutory Health Insurance Physicians of Westphalia-Lippe).
This is how long the retention period for patient data applies
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, claims for damages under civil law can be asserted up to 30 years after treatment.
Process optimization facilitates documentation
To keep documentation requirements as streamlined as possible, it helps to have a clear division of duties and outsource as many administrative tasks of healthcare staff as possible.
In addition, the documentation should be digitized right from the start. Paper should not be used at all. This is because it not only requires resources for production and disposal, but also for the physical storage of the documents.
These tips and tricks will make your work easier:
- Dictation machines and programs with speech recognition can save you a lot of time.
- Keep a checklist with your documentations. This will help you forget less and feel more confident.
- By keeping an electronic patient file, you always have access to the previous examination results and medical history. Substitute doctors are also sufficiently informed about your patients.
- Training courses for the entire team on the most common programs can reduce fear of digitalization.
Nelly helps you minimize the burden of documentation requirements
Software solutions such as Nelly are one way of optimizing processes: Because with Nelly, you can make patient admission completely paperless and thus save a lot of time. Take advantage of digitization so that documentation obligations don't rob you of any time for your actual profession. This benefits not only us doctors, but also patients and their families. We will advise you on your individual case free of charge and without obligation!
*names freely invented by the editors.
The personal designations used in this article always refer equally to all persons. For the sake of better readability, we have refrained from using double or opposite names.
When choosing a career, hardly any doctor expected a veritable flood of documentation requirements. Didn't you either? Rest assured, neither did I. As a doctor, I have pulled my hair out more than once at the word "documentation obligation". In this article, I will tell you about my experiences with the documentation obligation and everything you need to know about it. D'accord?
40 overtime hours per month due to documentation requirements
I only realized how much the documentation effort had changed my job as a doctor when a patient asked me about it. He was frustrated himself that he had to write down all his data up to four times (!) during the surgical admission.
As a result, the patient's experience in the hospital was negatively tainted. And of course mine as well. I had completely misjudged the daily work routine, as many other doctors did at the beginning. A minimum of forty hours of overtime per month is a bitter reality. And that is mainly due to the documentation requirements and not to the patient treatments.
The care of patients usually does not require a lot of time: conversation, examination and planning of therapy take about 30-40 minutes. Operations are an exception to this. However, documentation requires at least another 30-40 minutes. Completely overtired, I asked myself every now and then the serious question of whether I was really skipping the end of the day to do paperwork.
So it was not uncommon for me to use the nightly rest to prepare patient letters. This was the only way I could avoid working overtime on daytime duties. Unfortunately, due to my overtiredness, the quality of the nighttime documentation often left much to be desired.
Doctors document just under half of their working time
In the daily medical bureaucracy, rehab applications were always a particular thorn in my side. Four pages of cloze text, with 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. According to this study, doctors spend around four hours of their working time on documentation every day. That is about 44 percent of the total working time! Almost all respondents state that the amount of time spent on documentation and the level of detail required has increased.
Patient documentation creates risk of burnout
But what does everyday life look like apart from the statistics? Morning rounds with the entire team. Afterwards, examinations are requested, consults are written, doctors' letters are written and clarifications are 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 blood unit. Because then the actual doctor's job is called for. The price for the excursion into applied medicine: two hours of overtime and no lunch break.
So easily the time we doctors spend on documentation fluctuates and in my case amounts to up to five hours a day. Painfully, I have noticed that patient contact is becoming more and more distant and that even after-work time with the family is being replaced by patient letters and OR reports. Danger of burnout? Definitely.
The documentation obligation: what you need to know
As annoying as detailed documentation is, it is also necessary. On the one hand, it serves patient safety, as a memory aid for healthcare staff, as information for treating colleagues and also for billing purposes.
How to document correctly
The treatment contract obliges physicians to document. You can choose whether you want to document in electronic or paper form. Both are permitted. Make sure that the original content always remains recognizable, no information may be overwritten. Corrections can be dated.
The legal basis for the documentation obligation can be found in Section 630 f BGB of the Patient Rights Act. Unfortunately, there are no precise specifications as to what exactly must be recorded. From a professional point of view, all current and future treatments and results must be documented. The anamneses, diagnoses, findings, examinations incl. results, therapies/interventions and their effects, doctors' letters as well as consents and explanations are particularly important. The language of the documentation should be in specialist language and does not have to be understandable for laypersons. For more information on the documentation requirement, please visit the website of the Kassenärztliche Vereinigung Westfalen-Lippe (Association of Statutory Health Insurance Physicians of Westphalia-Lippe).
This is how long the retention period for patient data applies
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, claims for damages under civil law can be asserted up to 30 years after treatment.
Process optimization facilitates documentation
To keep documentation requirements as streamlined as possible, it helps to have a clear division of duties and outsource as many administrative tasks of healthcare staff as possible.
In addition, the documentation should be digitized right from the start. Paper should not be used at all. This is because it not only requires resources for production and disposal, but also for the physical storage of the documents.
These tips and tricks will make your work easier:
- Dictation machines and programs with speech recognition can save you a lot of time.
- Keep a checklist with your documentations. This will help you forget less and feel more confident.
- By keeping an electronic patient file, you always have access to the previous examination results and medical history. Substitute doctors are also sufficiently informed about your patients.
- Training courses for the entire team on the most common programs can reduce fear of digitalization.
Nelly helps you minimize the burden of documentation requirements
Software solutions such as Nelly are one way of optimizing processes: Because with Nelly, you can make patient admission completely paperless and thus save a lot of time. Take advantage of digitization so that documentation obligations don't rob you of any time for your actual profession. This benefits not only us doctors, but also patients and their families. We will advise you on your individual case free of charge and without obligation!
*names freely invented by the editors.
The personal designations used in this article always refer equally to all persons. For the sake of better readability, we have refrained from using double or opposite names.
Dr. med. univ. Lisa Raberger
Doctor & author
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