Me. 🙂
I chart as I go using a three-step process. The "pre-visit" takes place right before I go into the exam room. I look at the reason(s) for the visit, quickly review any labs or studies, look over the vitals, and hammer out a quick "normal" note for the problem(s) I expect to address (I use a lot of quick-text and pre-defined ROS and PE macros to make this easy). In the room (the "visit"), I spend most of my time talking to or examining the patient. Our rooms are set up so I can look at my tablet PC and still maintain eye contact with the patient. I'll add a few things to the note while we talk, usually in the HPI. At the end of the visit (the "post-visit"), as the patient is heading to the check-out window, I'll update my physical exam findings (if needed) along with my assessment and plan, pre-order any labs for the next visit, and tie up any other loose ends before submitting my charges and signing off on the note. Then it's on to the next patient.
This process not only lets me get my notes done in real time, but ensures that the bulk of the data entry is done outside the exam room, not in front of the patient.
I work with scribes in the free clinic that I volunteer at, and find that they slow me town tremendously. Moreover, their notes are far inferior to what I would have written on my own. The only reason I use them is because I'm not trained on the clinic's EMR.
