How to write reports and chart notes faster?

[Boston2k]

I find writing clinical chart notes and assessment reports to be slow, and wanted to see how others had different and better approaches. Right now, I usually take one of two approaches:

1. Right after a session, write down mostly from memory a gestalt summary of the sessions, then fill in other random details later (e.g., if I don't remember exactly how many times clients did a certain behavior) based on notes. This is good for getting things down on paper, but I am usually tired after a session, may have another session immediately after (and this increases fatigue going into that session, even if I have the time at all between sessions), and it is still irksome to go back and get all of the random details.

2. I will do several sessions, then write the notes in a batch. This permits for rest between sessions, but then I forget a lot of the process (harder to write the gestalt summary) and have to dig much harder through notes to recreate what happened.

For both of these, I will go through all paper notes to make sure I incorporated everything. I eventually get them done, but it can be pretty slow and painstaking, and this burden interferes with getting other work done.

Is there a way to get enough rest and not be annoyed, while getting the reports and notes done quickly? I would be very interested to hear about the specifics of your approaches and what works well/not so well. Thanks!!!

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[erg923]

Make them shorter. Use dictation software if you aren't a particular fast typer.

 

[Ollie123]

"Minimal professional standard" was arguably the most (only?) valuable lesson from internship. I spent way too much time on documentation as a trainee.

Obviously everything depends on culture in your setting, but my early notes read like a transcript of the session. My current notes are maybe 6-8 lines long. Reports - it depends whether it is a true assessment report (much higher standard) or just a regular intake that will be read by no one. If you are early in your training, it is normal and your notes will get much easier to write quickly over time. You probably aren't forgetting any more about what you do between sessions...you are most likely just including more details than the typical practitioner would.

 

[erg923]

"Minimal professional standard" was arguably the most (only?) valuable lesson from internship.

Can you elaborate on this. Interesting-does not seem consistent with what one would want to teach trainees?

 

[Ollie123]

Not much to say, it is what it sounds like!

Basically just an acknowledgement that as you ascend in your career it becomes more and more important to prioritize and accept that some things can be less than "perfect", as long as it meets minimal professional standards. Documentation is actually a fabulous example. Don't spend 10 hours writing a "perfect" report (whatever that is) when you can spend 1 hour writing one that would pass muster anywhere and the other 9 hours doing something more productive (more patients, research, spending time with your family so you don't go insane, etc.). Basically just a way to encourage professional triage. I think its an important lesson for trainees to hear once they reach a certain point.

It happened on internship, which seems like about the right time for it as folks start transitioning out into the "real-world."

 

[PsyDr]

1) Templates
2) Consider using the relevant laws as a source of structure for your notes.
3) Remember the purpose of the notes. It is to document the general purpose and findings, not defend yourself. Most referral sources are not going to read a 30page report. My initial reports were long as hell. Then i started watching physicians read my reports. Docs would just flip to the last page and read the summary. So why write anything else?
4) It is significantly easier to defend a limited report/note than it is to defend a lengthy one. I prefer for my expert witness reports to leave a bunch to the imagination because there is no reason to give opposing counsel prep material. That way when I am deposed, I can start throwing 800 references and extra info out there.
5) Following up on what Ollie said, in medical malpractice all you need is a "reasonable minority" that thinks what you are doing is okay. There are experts that will testify that one other person = reasonable minority. I use Donder's article to back up my short as hell reports.

 

[MCParent]

then fill in other random details later

That would be the reason.

Unless you have a supervisor who demands you include "random details" (which I can believe exist), why do this? With the exception of documenting something like suicidal/homicidal behavior/child endangerment, etc., what's the purpose of heavy details? Broad strokes are always much better, I find.

I had a supervisor who used to say, "If you can't write your note in 5 minutes, you're doing something wrong."

 

[WisNeuro]

Templates, templates, templates. Pretty much everything PSYDR said. My therapy notes take about 5 minutes to write, my neuropsych reports take about 45 minutes to write if it is straightforward, maybe 1-1.5 hrs if it's a little complicated.

 

[smalltownpsych]

For intake, I try to keep it to one page or two pages (was more like two or three during training) with sections for presenting problem, family/social hx, education and employment hx, psych hx, medical hx, mental status exam, and treatment plan. Usually takes about 10 to 15 minutes when dictated, 30 when typed myself.

For progress notes, I use the DAP format.
Data: Two or three sentences describing the main gist of the session. A couple more if there was a risk issue.
Assessement: A sentence on affect and mood for assessment and occasionally other significant mental status issues. Plan: Continue individual psychotherapy with focus on _____. This section will be longer when there is danger to self or others as I document the steps that were taken and rationale. Can usually do this in under 5 minutes, 10 when there is risk.

 

[erg923]

Templates, templates, templates. Pretty much everything PSYDR said. My therapy notes take about 5 minutes to write, my neuropsych reports take about 45 minutes to write if it is straightforward, maybe 1-1.5 hrs if it's a little complicated.

The neuropsychologists at my facility regular document 12-15 hours of 96118 for run of the mill clinical (often dementia or psych vs TBI) evals. This seems nuts to me. Am I off here?

 

[WisNeuro]

The neuropsychologists at my facility regular document 12-15 hours of 96118 for run of the mill clinical (often dementia or psych vs TBI) evals. This seems nuts to me. Am I off here?

12 hours for a routine dementia eval is insane. If it is a very straightforward memory disorder eval, minimal psych history, no real threat of an atypical dementia, I usually bill 1 unit 96116, and 6-7 hours of 96118. How much testing is this person doing? And, if it's all in one day, I question the validity of many of the later tests.

 

[Therapist4Chnge]

12 hours for a routine dementia eval is insane. If it is a very straightforward memory disorder eval, minimal psych history, no real threat of an atypical dementia, I usually bill 1 unit 96116, and 6-7 hours of 96118. How much testing is this person doing? And, if it's all in one day, I question the validity of many of the later tests.

Same. I try to avoid dementia evals (I personally think they are boring), but if I do one I can't see doing more than 3hr of testing and 3-4hr of review/report writing (in addition to the intake and feedback sessions).

For my standard TBI/CVA I used to give (via psychometrician) 6-8hr of testing and then use 6-8hr for review of records/report writing, but as I've advanced in my career I've realized much of what PSYDR wrote above. Now my testing batteries are shorter (4-6hr), my review and report writing is 3-4hr, and the length of my reports are shorter and much more targeted. If it is a forensic case, then it is a very different animal in regard to time spent.

 

[deleted343839]

I'm using dictation now and I love it.

Like others have mentioned, it's helpful to build up a little vocabulary of standard phrases or templates, especially if you do a lot of consults/intakes or other semi-structured activities. Depending on your record keeping system you might try macros, "smart phrases," voice commands, etc. to insert paragraphs or sentences as needed. Don't document anything that didn't actually happen, of course, but don't feel the need to be original every time, for instance, you document educating a patient about their condition or teaching a relaxation skill or referring them to XYZ. It's OK to "self plagiarize" as long as your notes are accurate and complete to the standards of your jurisdiction.

Whatever you do, get yourself into the habit of writing your notes on the same day (except for long reports). If you hold yourself to it, you'll have more incentive to start improving your productivity right away.

 

[PsyDr]

I think it all depends on the purpose of the eval, pt characteristics, and test selection. If we are just looking a diagnosis, ideally there would be a single test with perfect sens/spec. If we are looking to describe every possible ability, we'd want to give all the tests. Sometimes I read reports and it's like listening to a really insecure person trying to justify things.

 

[Therapist4Chnge]

Whatever you do, get yourself into the habit of writing your notes on the same day (except for long reports). If you hold yourself to it, you'll have more incentive to start improving your productivity right away.

This has been really helpful for my productivity, at least for my neuropsych reports. Having to pull together the history and background info takes a lot longer when I put it off until I get my results.

Templates and having a list of commonly utilized recommendations also helps. I still customize them for each pt, but it cuts down on repeating myself for the general info.

 

[AcronymAllergy]

Like many folks above, total eval time for my neuropsychs averages 8 hours, which includes records review and report writing.

Like T4C and MamaPhD, I've found that my writing productivity is much higher when I do it same-day. Plus, I just like the idea of have a 1-day turnaround on a neuropsych report. Unfortunately, with meetings, other administrative duties, etc., I'm not able to do that as often as I'd like.

Edit: As for report length, mine are equivalent to the longer ones I wrote on fellowship, but are longer than my pure Neurology rotation reports. It also varies by a page or so based on referral source. If it's primary care or Neurology, for example, it tends to be shorter. If it's psychiatry or psychology, I may spend a bit more time hashing out some of the MH-related factors that I feel would be relevant to them and their treatment going forward.

 

[Doctor-S]

I find writing clinical chart notes and assessment reports to be slow, and wanted to see how others had different and better approaches. Right now, I usually take one of two approaches:

1. Right after a session, write down mostly from memory a gestalt summary of the sessions, then fill in other random details later (e.g., if I don't remember exactly how many times clients did a certain behavior) based on notes. This is good for getting things down on paper, but I am usually tired after a session, may have another session immediately after (and this increases fatigue going into that session, even if I have the time at all between sessions), and it is still irksome to go back and get all of the random details.

2. I will do several sessions, then write the notes in a batch. This permits for rest between sessions, but then I forget a lot of the process (harder to write the gestalt summary) and have to dig much harder through notes to recreate what happened.

For both of these, I will go through all paper notes to make sure I incorporated everything. I eventually get them done, but it can be pretty slow and painstaking, and this burden interferes with getting other work done.

Is there a way to get enough rest and not be annoyed, while getting the reports and notes done quickly? I would be very interested to hear about the specifics of your approaches and what works well/not so well. Thanks!!!

Based on your avatar, I see that you are currently a "psychology student." As a psychology student, are you writing clinical chart notes and assessments in a particular type of setting - e.g., inpatient hospital, outpatient treatment facility, public agency site, pre-doctoral practicum site, campus site, etc?

For instance, in clinical medical/psych settings, many folks use the SOAP approach (Subjective information, Objective information, Assessment, Plan). So, you could use a psychiatric SOAP template if you're working with psych patients in a hospital venue.

If you're not working in a SOAP setting, you can try some other methods to streamline your notes and assessments (see below).

1. Form File Method (Templates).

You can assemble your own "form file" template.

To do this, you can review clinical chart notes/assessments that may have been prepared by someone else that are (in your opinion) outstanding - that is, if you have the authority, consent AND permission to review someone else's chart notes and assessments. Ask first!

If you are allowed to do this, make sure you redact/obliterate any and all identifying information related to anyone, in connection with privacy laws (HIPAA) or any other applicable policies, mandates, etc.

Similarly, you can ask some of your clinical training folks & supervisors to refer you to some excellent examples of clinical chart notes and assessments for this purpose. Thereafter, you can modify those references/templates, as needed for your own purposes.

2. Voice Dictation:

Agree with @erg923 and @MamaPhD.

I learned how to use voice dictation early in my career: it is quick, convenient and efficient. Plus, someone else is typing it for me so it is legible. Note: I always review my voice dictation documents to make sure everything is entered accurately (just in case I was mumbling or speaking too quickly) before I sign my name on any chart note/assessment, etc. If voice dictation is offered at your site, try it out, and see if it helps you.

3. Practice to Become More Proficient (and Faster).

After a while, you will probably be able to prepare clinical chart notes/assessments much more quickly and much more efficiently as you progress through your psych training. As a psychology student, you have the luxury of practicing these useful skills before things inevitably grow more complicated in your career (e.g., after you graduate from school). So, if you practice these skills (at this stage in your training - even though you're feeling pressed for time and exasperated), you'll likely become much more proficient over time. It's a rite of passage for nearly everyone.

Thank you.

 

[Therapist4Chnge]

Like many folks above, total eval time for my neuropsychs averages 8 hours, which includes records review and report writing.

Like T4C and MamaPhD, I've found that my writing productivity is much higher when I do it same-day. Plus, I just like the idea of have a 1-day turnaround on a neuropsych report. Unfortunately, with meetings, other administrative duties, etc., I'm not able to do that as often as I'd like.

Those are like unicorns and leprechauns! A brief battery for an in-pt case with a very specific referral question is doable, but not for the typical out-pt. referral (at least for the cases I get). Dealing with getting outside records is often a hold up and then trying to reconcile the current medical record with the outside records with my report takes a chunk of time. The interpreting, writing, and providing recommendations tends to be pretty straight-forward.

 

[WisNeuro]

Those are like unicorns and leprechauns! A brief battery for an in-pt case with a very specific referral question is doable, but not for the typical out-pt. referral (at least for the cases I get). Dealing with getting outside records is often a hold up and then trying to reconcile the current medical record with the outside records with my report takes a chunk of time. The interpreting, writing, and providing recommendations tends to be pretty straight-forward.

Ah, one of the benefits of the VA, many of our patients have extensive records all within the system. For many patients I can do my interview, write up most of the report while my psych tech is testing, and finish the report in the afternoon after I have my results. Having a trainee slows things down a little bit, at that point I'm usually in the 7-10 day turnaround range.

 

[Therapist4Chnge]

I try and stay around 2 wks. Some are quicker (dementia, failed effort) and some are longer (poly-trauma w outside records, VA referrals, etc).

 

[Boston2k]

This is a tremendous wealth of insight - thank you! Hopefully trimming down details, using dictation, writing notes on the same day, and using templates will all serve me well. A couple of follow-up questions:

PSYDR - That is a very good point to consider the legal standard. Would you recommend a concise source for legal issues in note writing (and practice in general)? I have received general training and also specific instructions for our state, but presumably I will move states and also it would be good to have more information about the general legal issues (e.g., I was not aware that reasonable minority = 1 person). Also, what is Donder's article (A google search found Donders' law but not much more for me)?

WisNeuro - 45 minutes for a neuropsyc report is great! Would you mind briefly indicating the steps you take to write this way (e.g., get all the scores together, then list main points to highlight, then dictate section 1 in the template, then section 2, or however it might go)? The specific process would provide even more insight into how this is done.

To answer Doctor-S - I am writing both clinical chart notes and assessments. My biggest problem is with assessments - both in a psych department clinic as well as outpatient hospital. Brief chart notes I can do quickly, but the assessments seem to take forever.

 

[PsyDr]

There's no training that I know of. I read up on medical malpractice. Then I used my state's specific requirements for assessments as a template for how my report structure flows. I get a board complaint, they will have a hard time getting me on structure. Medical malpractice is very unlikely since the majority of my work is protected by expert witness immunity.

Jacobus Donders is the author of several articles and a book regarding report structure.

 

[WisNeuro]

WisNeuro - 45 minutes for a neuropsyc report is great! Would you mind briefly indicating the steps you take to write this way (e.g., get all the scores together, then list main points to highlight, then dictate section 1 in the template, then section 2, or however it might go)? The specific process would provide even more insight into how this is done.

Well, I usually have all of my scores in a handy data table from a spreadsheet that I have that works for me. But, the most helpful thing is that I have templates for any kind of patient that I have seen in the past (e.g., normal cognitive aging, MCI, early AD, Vascular Dementia, failed effort, etc). Once you have these templates, it's pretty much just plug and play for a lot of the report. I can write the background and results in about 10 minutes, really. And then I can tinker around with my summary and rec for however long I need depending on complexity. Of course, being able to efficiently gather info from chart review and organize however you feel on a background sheet helps as well.

Honestly, it's hard to do more feedback than that on a forum, this is stuff that I cover through multiple supervision sessions with my students.

 

[Boston2k]

Thank you, PSYDR and WisNeuro!

 

[Justanothergrad]

1. Reduce inclusion of irrelevant information, thereby shortening note
2. use templates to include basic information so you don't have to type a lot of the formatting out, shortening how much you type into the note
3. When possible, do notes in session.

I end up having a "Client statements:" section at the top of my notes after the date/time/billingcode/client name where I type/write stuff in during session. This is where most of the meat of the session is. It'll have a series of short statements that reads something like, "Client statement: I'm still sad all the time... never smile... wife keeps picking fights with me... I can't stop her.." What comments I focus on depends on the problem and what type of treatment I'm doing. It provides a great opportunity to justify billing extensions because direct quotes are great.. will include verbatim SUDS response to whatever the presenting diagnosis is as well (e.g., "depression is a 10 of 10 today, been like that all week"). I'll stop someone when they say things and say 'hold on, you just said something really powerful/interesting/important- let me write that down'. it gives an interesting opportunity to reflect on the exact wording they used later (clients tend to like it because they can see how much their language/perspective changes) and it also gives me quotes to incorporate into assessments. Then I have a intervention section where I include a few sentences afterwards (seriously, a few) about what I did clinically and any important information on treatment response/dosage/etc. This later part doesn't tend to be more than a few sentences so it's easy to get finished with quickly post-session. In general it works with my approach to a session. 5 minutes to bitch (everyone gets that), 15 minutes to catch up on life (me filling in the client statements with some challenges), then the rest of the session being intervention.. often with me referring back to client statements to work on cognitive distortions, timing for behavioral interventions, etc. So if its an anger client, i'll jot down what they say about when/where/why they got angry and then in the intervention just mention things like "reviewed relaxation exercises, processed about ways to incorporate breaks into conversation with wife to avoid anger and role-played different conversational approaches utilizing healthy communication strategies". Add a few more brief details that would be useful if someone needed to step in for me in a pinch/if they transfered... move on.

 

[Terri Dactyl]

Practice, practice, practice and always improve your writing style. Like I've told my students, be diligent that your clinical writing is clear and concise. Say in one sentence what you have written in four. Leave out extraneous info and only that is clinically relevant.

Regardless of templates, if you're writing info irrelevant to the purpose of the service and using frivolous wording then you're wasting your time and the reader's. I average 5 mins on progress notes; 45 mins for 2-3 page intakes; however, full batteries can vary in time due to complexity, especially if incorporating parent/teacher measures, but avg. 7 hrs including scoring.