Paperwork?

[maybepsych]

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Do you feel like Psych has more paperwork and documentation involved compared to other specialties?

If you broke down your work hours what percent would you say is spent with patients vs. paperwork?

Thanks.

 

[masterofmonkeys]

Do you feel like Psych has more paperwork and documentation involved compared to other specialties?

If you broke down your work hours what percent would you say is spent with patients vs. paperwork?

Thanks.

As a resident it is darn near 50/50. And no I am not joking.

This will be different from state to state, hospital to hospital, attending to attending. But in a private hospital in Colorado this has been my experience.

 

[kugel]

Psych ER: 40-50% paperwork.

 

[Doc Samson]

Define paperwork? Notewriting? Really no more than on medicine dictating H&Ps and discharge summaries. Insurance stuff - my staff takes care of it.

 

[maybepsych]

Define paperwork? Notewriting? Really no more than on medicine dictating H&Ps and discharge summaries. Insurance stuff - my staff takes care of it.

I used paperwork as a general term to basically include all writing that you do.

I asked this because on my medicine rotation the other day I made a comment how I was surprised by how much note writing/form filling/ etc. is required for a patient on a daily basis. One of my residents then made the comment to not go into Psych because it requires so much more documentation.

So I asked the question to see if what they said was true. Does Psych really require so much more documentation/paperwork than other specialties?

Also, I know Obama has brought the issue up several times but do you believe that the amount of "paperwork" that physicians will have to do will ever decrease. I recently heard there are new laws on the horizon that may actually increase the amount of documentation required on a daily basis.

Thanks for your input.

 

[Doc Samson]

I used paperwork as a general term to basically include all writing that you do.

I asked this because on my medicine rotation the other day I made a comment how I was surprised by how much note writing/form filling/ etc. is required for a patient on a daily basis. One of my residents then made the comment to not go into Psych because it requires so much more documentation.

So I asked the question to see if what they said was true. Does Psych really require so much more documentation/paperwork than other specialties?

Also, I know Obama has brought the issue up several times but do you believe that the amount of "paperwork" that physicians will have to do will ever decrease. I recently heard there are new laws on the horizon that may actually increase the amount of documentation required on a daily basis.

Thanks for your input.

A typical H&P for psychiatry is really no longer than for medicine and can be made much easier to do with check-box templates, tablet PCs, or just good old-fashioned dictation. Daily progress notes are similarly not too different from any of the other specialties (except, of course, surgery where the notes barely seem to indicate that the patient was examined).

There are options in psychiatry that are notoriously writing-heavy (forensics for instance), but general practice isn't really that different from anything else.

 

[whopper]

I do not think the paperwork is any worse than the other fields of medicine in terms of the amount. I do think that paperwork in psychiatry is different than the other fields because our conclusions requires descriptive details as to why we came to them, while the other fields do not require as much.

E.g. BP 100/60---easy.

In psychiatry if you think someone is paranoid, you shouldn't just write down "paranoid", you should also write down your evidence for reaching this conclusion.

"Patient exhibits paranoia as evidenced by hypervigilance (eyes wide open and scanning the room on a continual basis), guarded thought process, and making demands to be left alone out of fear of being attacked "you better get away from me, I know you're going to do something to me!"

 

[michaelrack]

In some settings, such as many community mental health centers, you have to do a consent form for every med you prescribe.

 

[masterofmonkeys]

consent forms, treatment planning, involuntary commitment, involuntary meds, seclusion and restraint, etc, etc, etc.

And on progress notes, mine are a page long 10 point font, not by choice.

 

[whopper]

At the places I've worked at, the treatment team staff write up the treatment plans. In fact they pretty much write up everything except the progress note, H&P & discharge summaries.

I just got to read them, agree with it & sign it, or disagree, tell them what needs to be corrected, add my input, then sign it.

That is nice because those treatment plans in a long term facility can take hours. In a short term facility it only takes minutes (at least from my experience).

consent forms, treatment planning, involuntary commitment, involuntary meds, seclusion and restraint, etc, etc, etc.

Consent forms aren't hard. You just explain the medication (which is what we're supposed to do anyway even without the consent form) then they sign it. The commitment papers, & involuntary meds now that does take time, but IMHO every field has some sort of unique thing that they have to document. E.g. surgeons have to write post op notes & dictations.

All in all-there is just as much documentation in this field as any other, but there are things we have to document, and in a different way than the other fields of medicine.

 

[Yoyomama88]

I really don't enjoy writing up H&P's or progress notes by hand. Will hospitals/offices in the future likely have everything electronic so it can always be typed up?

Also which medical specialty has the least amount of note taking? Radiology?

 

[Armadillos]

Also which medical specialty has the least amount of note taking? Radiology?

Go spend some time in the reading room, documentation is essentially the whole reason radiologists exist

 

[Yoyomama88]

Yea but they dictate. Dictating seems much more bearable to me than writing. Dictation > Typing > Writing by hand in my opinion.

 

[splik]

well there is no reason you have to write by hand. I almost never make notes when seeing patients because I feel it gets in the way. Maybe twice in the past year have I jotted down notes. Also there is no reason you have to dictate admissions, discharges, clinic notes - these can all be dictated if you become au fait with using dictation. Personally I enjoy writing, so I type all my notes and I tend to write quite long, descriptive assessments but am in the minority. It is not necessary and there are certainly advantages and disadvantages to a narrative style vs check box template style.

 

[wolfvgang22]

In my general psych residency, the documentation was 50% of the work. Now in child fellowship it's about 85% of the work. I think a lot of it has more to do with where I'm at than what I'm doing.

 

[wolfvgang22]

I really don't enjoy writing up H&P's or progress notes by hand. Will hospitals/offices in the future likely have everything electronic so it can always be typed up?

Also which medical specialty has the least amount of note taking? Radiology?

Probably a surgical specialty, and then it still depends on where you go.

 

[shan564]

We do all of our H&Ps by dictation, and all of our discharge summaries are typed or dictated. Our H&Ps are definitely way longer than in IM or other specialties, but I kinda like being able to spell out my thought process via dictation... it was really difficult the first few times, since our H&Ps are actually graded, but it was fine after that.

Our daily progress notes are handwritten, but that's probably changing to electronic soon. We have pre-printed electronic notes that already have a good chunk of the note printed (labs, meds, etc.), and I just have to fill in my subjective, my MSE, and my A/P. And our EMR is probably more primitive than most places. There are a lot of places that are entirely electronic.

As an intern, I probably do more paperwork than most other years. I spend about 1-2 hours a day writing notes, depending on how many patients I have. If I do it efficiently, I can usually do a lot of my note writing during ward rounds. In a typical day, I spend about an hour pre-rounding, 2 hours on a ward round, 1-2 hours in didactics, 1-2 hours teaching students, and the rest of the time doing various different things.

 

[CounselortoMD]

Off the top of my head, this is some of the paperwork I had to fill out (all by hand) for each patient whom I admitted to our inpatient psych facility:

1) Twelve page Interdisciplinary Psychosocial Assessment
2) Initial Problem List/Treatment Plan
3) Admission Agreement (if voluntary)
4) Involuntary Patient Rights (if not voluntary)
5) Firearm Notification (if not voluntary)
6) HIPPA Acknowledgement
7) A separate Release of Information Form for each of the patient's providers and family members
8) School District Documents (for under age 18)
9) Coordination of Benefits Form
10) H&P Billing Form
11) Seclusion/Restraint Notification Form
12) High Risk Indicator Form for pass-off communication to unit staff
13) Sexual Aggression Assessment
14) Communicable Disease Screening Form
15) Take and print a Photo for patient identification
16) Medicare Rights Disclosure
17) Medicare Flowsheeet to determine if primary payor
18) EMTALA Log for JCAHO
19) Administrative Review Log used as a precert checklist
20) Intake/Triage Form
21) Round Sheet for Q15 minute safety checks
22) Restricted Visitor List
23) Approved Visitor/Caller List (for under age 18)
24) Time Study Flowsheet (to improve efficiency and reduce wait times--oh, the irony!)

 

[whopper]

Just wanted to add, a lot of this can vary per institution you work at. Some hospitals don't have dictation. Yes ridiculous but true. I'm a University Hospital in Cincinnati and dictation is not an option in all forms of record keeping. It used to be. Since we've taken in EPIC, they've had problems incorporating it into some of EPIC even though you can use dictation for any of it.

Some places want you doing treatment plans, others do not. In general, most places will not want the doctor doing something cost-ineffective. E.g. a nurse can write one up, freeing time for the doctor to do more cost-effective things because the doctor is the golden goose of the treatment team, but I've seen a few institutions here and there not do this out of stupidity.

 

[shan564]

Off the top of my head, this is some of the paperwork I had to fill out (all by hand) for each patient whom I admitted to our inpatient psych facility:

1) Twelve page Interdisciplinary Psychosocial Assessment
2) Initial Problem List/Treatment Plan
3) Admission Agreement (if voluntary)
4) Involuntary Patient Rights (if not voluntary)
5) Firearm Notification (if not voluntary)
6) HIPPA Acknowledgement
7) A separate Release of Information Form for each of the patient's providers and family members
8) School District Documents (for under age 18)
9) Coordination of Benefits Form
10) H&P Billing Form
11) Seclusion/Restraint Notification Form
12) High Risk Indicator Form for pass-off communication to unit staff
13) Sexual Aggression Assessment
14) Communicable Disease Screening Form
15) Take and print a Photo for patient identification
16) Medicare Rights Disclosure
17) Medicare Flowsheeet to determine if primary payor
18) EMTALA Log for JCAHO
19) Administrative Review Log used as a precert checklist
20) Intake/Triage Form
21) Round Sheet for Q15 minute safety checks
22) Restricted Visitor List
23) Approved Visitor/Caller List (for under age 18)
24) Time Study Flowsheet (to improve efficiency and reduce wait times--oh, the irony!)

Wow, that's insane. When I admit a patient, I just have to do a brief allergy form (30 seconds), a med reconciliation form (0-5 minutes, depending on how many meds the patient is taking... but if the patient was in the ED for a while, the pharmacy has already completed this form for me and I just need to sign it), an abbreviated H&P template form (10 minutes, and 75% of it can be completed while talking to the patient), and my dictated H&P. The rest of the stuff, including most of the things on your list, is done by ancillary staff.

 

[deleted307836]

Off the top of my head, this is some of the paperwork I had to fill out (all by hand) for each patient whom I admitted to our inpatient psych facility:

1) Twelve page Interdisciplinary Psychosocial Assessment
2) Initial Problem List/Treatment Plan
3) Admission Agreement (if voluntary)
4) Involuntary Patient Rights (if not voluntary)
5) Firearm Notification (if not voluntary)
6) HIPPA Acknowledgement
7) A separate Release of Information Form for each of the patient's providers and family members
8) School District Documents (for under age 18)
9) Coordination of Benefits Form
10) H&P Billing Form
11) Seclusion/Restraint Notification Form
12) High Risk Indicator Form for pass-off communication to unit staff
13) Sexual Aggression Assessment
14) Communicable Disease Screening Form
15) Take and print a Photo for patient identification
16) Medicare Rights Disclosure
17) Medicare Flowsheeet to determine if primary payor
18) EMTALA Log for JCAHO
19) Administrative Review Log used as a precert checklist
20) Intake/Triage Form
21) Round Sheet for Q15 minute safety checks
22) Restricted Visitor List
23) Approved Visitor/Caller List (for under age 18)
24) Time Study Flowsheet (to improve efficiency and reduce wait times--oh, the irony!)

I see you're a med student - am I correct in assuming a resident/attending usually wouldn't be filling out all these forms at your facility? Some of them seem very appropriate for nursing, instead.

 

[deleted307836]

Wow, that's insane. When I admit a patient, I just have to do a brief allergy form (30 seconds), a med reconciliation form (0-5 minutes, depending on how many meds the patient is taking... but if the patient was in the ED for a while, the pharmacy has already completed this form for me and I just need to sign it), an abbreviated H&P template form (10 minutes, and 75% of it can be completed while talking to the patient), and my dictated H&P.

I guess I could have read this post before posting the above. This seems much more reasonable.

 

[CounselortoMD]

I see you're a med student - am I correct in assuming a resident/attending usually wouldn't be filling out all these forms at your facility? Some of them seem very appropriate for nursing, instead.

I think most of these papers could be filled out quite easily by a 6th grader with borderline intellectual functioning, or an octogenarian suffering from mild to early-moderate stages of dementia--although probably not rapidly enough, in either scenario, to keep the human assembly line churning out admissions 24/7 with lightning-fast pace--the expected standard which was constantly demanded by administration of my former hospital.

Also, I'm not quite sure what you meant by the term "ancillary" staff, or your suggestion that the tedious menial process of filling out all this idiotic paperwork, should be automatically relegated to non-physician members of the treatment team such as nurses--or, in my particular situation, a master's-level psychotherapist possessing many years of experience--along with a professional license, which required eight years of full time training, allowing me to design appropriate treatments for my patients and to provide care for them as a fully autonomous clinician. (Although I would never describe my role as "independent", since I despise the notion that ANY healthcare professional should ever practice within the dangerous isolation of an all-knowing bubble.)

Anyway, I apologize for getting so militant up on this soap box, but I just hate the fact that it was always my responsibility to make sure these endless stacks of useless papers were filled out perfectly for every patient! Unfortunately--and this is the most frustrating part--this relentless duty of shuffling mountains of rote paperwork sometimes became so overwhelming that it detracted from the quality of my intake assessments: which were , in fact, the single clinically-useful instrument, actually conveying truly important information, that I was ever required to use--and also the only document to ever cross my desk which necessitated any level of professional knowledge (beyond that obtained in high school) to complete.

 

[shan564]

Also, I'm not quite sure what you meant by the term "ancillary" staff, or your suggestion that the tedious menial process of filling out all this idiotic paperwork, should be automatically relegated to non-physician members of the treatment team such as nurses--or, in my particular situation, a master's-level psychotherapist possessing many years of experience--along with a professional license, which required eight years of full time training, allowing me to design appropriate treatments for my patients and to provide care for them as a fully autonomous clinician. (Although I would never describe my role as "independent", since I despise the notion that ANY healthcare professional should ever practice within the dangerous isolation of an all-knowing bubble.)

I can understand your frustration at comments like that, I don't think that was the implication. I think the implication was that tedious tasks like that should be performed by somebody who doesn't cost the hospital (and therefore, the taxpayer/insurance premium payer) as much money. Somebody has to do the task - why not have it done by somebody can do it just as effectively, but not as expensively?

That said, I don't think that a psychotherapist should be doing it either.

 

[CounselortoMD]

I can understand your frustration at comments like that, I don't think that was the implication. I think the implication was that tedious tasks like that should be performed by somebody who doesn't cost the hospital (and therefore, the taxpayer/insurance premium payer) as much money. Somebody has to do the task - why not have it done by somebody can do it just as effectively, but not as expensively?

That said, I don't think that a psychotherapist should be doing it either.

I agree with your astute post, and I fully admit that I was being over-sensitive. I know it's not an excuse, but just to shed some light on the precipitating circumstances--I am totally overwhelmed and completely stressed out right now by my Gross Anatomy class. (We're currently on the neck and head section, and I am stumbling my way through the nightmare of learning all this material--while feeling like a complete ***** through the entire process.)

So I apologize for succumbing to my immature impulse to be downright disagreeable--simply for the sake of doing so. As I was reading that post to which I responded, I'm sure that I was petulantly searching for any reason I could find to pick an argument--and ultimately to perseverate into a self-righteous rant about something.

(My bad.) But I hope everyone will wish me luck in retaining enough information about the neck/head to somehow pass my Gross Anatomy course! Any positive energy sent my way is greatly appreciated!

 

[Doctor Bagel]

Just wanted to add, a lot of this can vary per institution you work at. Some hospitals don't have dictation. Yes ridiculous but true. I'm a University Hospital in Cincinnati and dictation is not an option in all forms of record keeping. It used to be. Since we've taken in EPIC, they've had problems incorporating it into some of EPIC even though you can use dictation for any of it.

Some places want you doing treatment plans, others do not. In general, most places will not want the doctor doing something cost-ineffective. E.g. a nurse can write one up, freeing time for the doctor to do more cost-effective things because the doctor is the golden goose of the treatment team, but I've seen a few institutions here and there not do this out of stupidity.

My hospital is like that. I think they used to have dictation for a fee, but I believe it's entirely gone now, and we're all using EPIC. I have dictated maybe 3 or 4 times in my life all on one rotation, so the thought of working somewhere where I would have to dictate scares me. I assume I'd pick it up quickly, but it's not a skill I've gained.

My thought about documentation in general is that it takes the time you've got allotted for it. If you've got endless time, you spend a lot of time doing it. If your time is constricted, you'll get it done quickly. I'm not really sure the documentation from when you have more time is higher quality either.

As the inpatient system leaves you with more time allotted for documenting (all the downtime during your day/shift), it takes up more of your time. As an intern and PGY2, documentation probably took up 50% or even more of my time. In an outpatient setting, you really don't have allotted time for documentation, and now I'd say it takes up maybe 25% of my time or even less. I don't do concurrent charting, either, because it doesn't work for my brain, and I don't think it's fair to patients.

 

[gibits]

Better start liking paperwork no matter your specialty. On the plus side, EMR could make things easier if you have templates set up so you can copy and paste or edit as needed. I'd say the time I spend on paperwork and talking to patients is 50/50 since I am writing non stop the instant they enter my office.
For demented patients it's even less face to face since they don't give much history. If you count gathering collateral info, chart review then id say "paperwork" time is even more of that ratio, nearing 70/30.