D
da8s0859q
I'm a "new guy" out of residency. Much prefer being an attending. Imagine that.
I'm very careful and particular about my notes. I'm sure the residents and midlevels at my hospital roll their eyes a little, but hey, they're my notes (or attestations), and they exist for some good reasons.
We use Epic.
I'm debating what is the most efficient way to handle documentation when you're a little bit of a detailed documenter. What I did for residency was just do the HPI, ROS, and PE after seeing the patient. I would pend the note and leave the MDM, EKG interpretations, so forth, to the end of shift (or do it in a five minute break if there ever was one).
I don't use the click-through HPIs in Epic. I free-text (dictate) all of it, list pertinent +/- in the HPI, and use a disclaimer for the ROS. I use macro-based exams that are quick and which I constantly refine.
What would be better? In a place where 3-4 pph happens routinely, is it better to dictate MDM in bits with timestamps as the ED course progresses and "touch" the MDM that many more times for the sake of not having to do so many notes after the fact, but at the cost of picking up a few more charts?
For resident and midlevel charts, better to have them use the "Share" function in Epic so I can addend their notes in real-time? Do a separate mini-note?
Something else?
I'm finding that notes to my standards are taking entirely too much time.
I'm very careful and particular about my notes. I'm sure the residents and midlevels at my hospital roll their eyes a little, but hey, they're my notes (or attestations), and they exist for some good reasons.
We use Epic.
I'm debating what is the most efficient way to handle documentation when you're a little bit of a detailed documenter. What I did for residency was just do the HPI, ROS, and PE after seeing the patient. I would pend the note and leave the MDM, EKG interpretations, so forth, to the end of shift (or do it in a five minute break if there ever was one).
I don't use the click-through HPIs in Epic. I free-text (dictate) all of it, list pertinent +/- in the HPI, and use a disclaimer for the ROS. I use macro-based exams that are quick and which I constantly refine.
What would be better? In a place where 3-4 pph happens routinely, is it better to dictate MDM in bits with timestamps as the ED course progresses and "touch" the MDM that many more times for the sake of not having to do so many notes after the fact, but at the cost of picking up a few more charts?
For resident and midlevel charts, better to have them use the "Share" function in Epic so I can addend their notes in real-time? Do a separate mini-note?
Something else?
I'm finding that notes to my standards are taking entirely too much time.