specalites with the least amount of note taking

[randommedstu]

i hate writing notes..which specialties have the least amount of note taking?

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[Jolie South]

Anesthesia and Emergency Medicine.

 

[McGillGrad]

Nursing and physician assistant.

 

[Richspiders07]

...Emergency Medicine.

beg to differ - in EM you are doing multiple focused H&Ps an hour. It helps of you have scribes... but you still have to chart A&Ps, Discharge instructions, etc.

But yes, there is no daily morning round note saying the patient ate and had a bowel movement yesterday if that's what you are concerned about.

 

[Jolie South]

beg to differ - in EM you are doing multiple focused H&Ps an hour. It helps of you have scribes... but you still have to chart A&Ps, Discharge instructions, etc.

But yes, there is no daily morning round note saying the patient ate and had a bowel movement yesterday if that's what you are concerned about.

I agree, but have you seen EM notes? In my facility, they fill out those T-sheets which are essentially check lists of symptoms and findings. Half the time they don't even bother to put an A&P aside from "admit to medicine" or "admit to surgery." They take like 2 minutes per note, if that.

 

[Rendar5]

I agree, but have you seen EM notes? In my facility, they fill out those T-sheets which are essentially check lists of symptoms and findings. Half the time they don't even bother to put an A&P aside from "admit to medicine" or "admit to surgery." They take like 2 minutes per note, if that.

EM typically doesn't write A&P's. WE write H&P and multiple follow-up notes and about 3-5CYA notes per pt. Less notes than medicine, more than surgery.

Go for psych

 

[ShyRem]

surgery notes are pretty darn short. And their H&Ps are short and to the point. Not comprehensive like medicine H&Ps.

 

[Jolie South]

EM typically doesn't write A&P's. WE write H&P and multiple follow-up notes and about 3-5CYA notes per pt. Less notes than medicine, more than surgery.

Go for psych

But you have to pitch it as something to the guys upstairs, even if it's a shady diagnosis.

You seem more thorough than the EM folks at the county hospital I worked at. Those patients were lucky to get one note on a T sheet.

 

[erectorspinae]

Nursing and physician assistant.

are you kidding? that's why we keep them around.

(jokes)

 

[BigRedBeta]

Radiologists dictate everything...

 

[Rendar5]

But you have to pitch it as something to the guys upstairs, even if it's a shady diagnosis.

You seem more thorough than the EM folks at the county hospital I worked at. Those patients were lucky to get one note on a T sheet.

well, what I told you was ideal and something I'm not quite at yet with my own time management (gotta try some ideas to keep up the CYA notes). The only thing to add is that our P is simply what we actually do (no point writing it because it's not something to pass along to someone else) and our A is the prelim diagnosis we give on sending them upstairs after talking with the attending/resident/whoever

 

[Zoom-Zoom]

surgery notes are pretty darn short. And their H&Ps are short and to the point. Not comprehensive like medicine H&Ps.

true. Although some surgical specialties like ENT are extremely nit-picky for notes as far as billing is concerned. the approach, specific parts of the procedure, indications for surgery and the thourough assessment all have to be there, and I could imagine it's a total PITA with such high volume. I'd assume the CYA factor comes into play with surgery a lot too. But still, despite this, I feel like surgeons tend to do less note taking than a lot of other medical specialties.

 

[Pinner Doc]

I agree, but have you seen EM notes? In my facility, they fill out those T-sheets which are essentially check lists of symptoms and findings. Half the time they don't even bother to put an A&P aside from "admit to medicine" or "admit to surgery." They take like 2 minutes per note, if that.

Sure, but that's ONLY if we're admitting a patient. With any patient we're discharging (which can be the great majority), we have to dictate everything we thought of and everything we did to rule those things out... in order to cover our *****es. It's not fast.

 

[Ableton]

true. Although some surgical specialties like ENT are extremely nit-picky for notes as far as billing is concerned. the approach, specific parts of the procedure, indications for surgery and the thourough assessment all have to be there, and I could imagine it's a total PITA with such high volume. I'd assume the CYA factor comes into play with surgery a lot too. But still, despite this, I feel like surgeons tend to do less note taking than a lot of other medical specialties.

I don't think they're really talking about operative reports in this thread. All of those are, and should, be detailed regardless of the surgical subspecialty. But they're usually dictated and are either done by a resident or take no longer than 5 minutes post-op while you're waiting for anesthesia to wake up the patient.

When it comes to consults and H&Ps, surgery notes are pretty damn short since they really only need to tell the reader one thing - surgery or no surgery.

 

[GoodmanBrown]

Anesthesiology for sure. No pre-approvals or anything helps.

 

[MossPoh]

Radiologists dictate everything...

Yea, but depending on the system you are using that can be quite cumbersome. A lot of places use voice recognition software. While better than the past, even a 1% error rate is a pain in the arse. If you are good with macros and can speak clearly then you can fly though. Also, if you aren't anal with the structure you can haul, but then anyone who reads your study hates your blob of information they have to weed through.

In a couple of years it will probably be pretty awesome though.

 

[illixir]

Surgeons take much less notes compared to medicine in terms of what you're asking the patient. You don't take any notes during an operation you just remember it all and write/dictate it later. Usually residents do that, the attendings don't do much note writing at all, zero note taking. Any specialty that sees patients will have clinic notes but you can shift those duties to other people as mentioned but at a cost.