Average time to write up psych ed note?

[MysticHealer]

Catching flack as a PGY2 for taking longer than half an hour to type a whole cc, hpi,psych ros, past psych hx, medical, surgical, social hx MSE and formulation and plan. On a board style blind patient after a 30 min interview.

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[billypilgrim37]

You don't have a 15-30 option, which might be a popular choice.

It really depends on the case. I have had ER cases that took me 45 minutes start to finish, and I have had ER cases that lasted 4.5 hours with me doing nothing but working on that case. The notes frequently reflect that. If I send someone out that I am a little worried about them but, say, don't have grounds to hold them, I spend a lot longer documenting the hell out of my risk assessment. If I'm admitting someone who wants to come in, that same section is just a line or two. Kid and geri cases can get bawled up and take forever, including writing them up. When I work late at night, it probably adds 10 minutes to every note, because I don't have the attention to keep on task.

 

[F0nzie]

Keep in mind you're still relatively early in your training and that it may take you some extra time to articulate into words your HPI and formulation. And of course, your attendings will read your notes and it's natural to want to make a good impression. Scale back a bit if perfectionism is slowing down your game. If your colleagues/attendings are giving you negative feedback about your pace, I would take it seriously. You don't want to be perceived as lazy. It's not uncommon that I've seen interns take 3 hours to do a single emergency eval, so don't feel bad.

But here are my thoughts:

The fact that you are interviewing patients and typing up the note later is a huge pitfall. I typically finish 75% my documentation (whether writing or typing) during the interview. If your institution is using EMR, look into getting a mobile laptop or a COW (computer on wheels) if your facility provides one.

Since computers can be a barrier to the relationship, I typically tell my patients "I will be typing notes, but I am listening". That way they understand and don't feel dismissed right off the bat. Get some practice with your typing speed and not looking at the keyboard so that you can stay engaged with the patient. Keep the computer off to the side so that it is not an obstacle between you and the patient. I use a personal netbook in the outpatient setting to document my intakes and it has not been a problem.

Are you really only spending 30 minutes during your interview? It's almost paradoxical that you could be fast in the most difficult area to be fast in psychiatry and slow at writing your note. Maybe you're a fast talker and a slow typer. Perhaps you are misjudging the time you really spend with patients. 45 minute interview + 45 minute note = 1.5 hours. This is too slow for a bread & butter or uncomplicated patient if you have a busy service. If your interviews are too long, consider cutting some questions out or using more closed ended questions without severely compromising your evaluation.

Keep in mind these are emergency evaluations. It's inherent in the name that you have to be fast and your eval has to be somewhat dirty. If you are not keeping up to speed in the ED because of the time it takes you to write your notes, I would seriously consider quick bathroom breaks, walking fast, keeping snacks in your pockets, and picking up the pace in other areas. If you're slow and you use the same strategy over and over, you're likely to get the same result- slow. So keep trying different strategies until your speed is no longer an issue. You will appreciate your colleagues who work fast and vice versa. Nobody likes a stack of hand-offs at the start of their shift. Nobody likes to work with lazy colleagues or colleagues that are so OCPD that it takes them forever to write a note.

No hard feelings. Just being straight up with you. Hope it helps.

 

[beezley]

20-25 minutes to type it up, start to finish, assuming there is nothing to cut/paste from previous notes. The HPI and Formulation are the most important and need to be inclusive but concise. Quick and dirty. Figure out whether they need to come in or not and the details and complete treatment plan can be figured out by the day team.


This is a xx yo m/f presenting to the er this evening with the complaint of x. There is a known diagnosis of xxx. (Immediate precipitates/stressors) and they note days/weeeks/months of blah blah blah (symptoms) and THEY CAME TO THE ER TONIGHT BECAUSE.

Psych ROS
Psych HX
Med Hx
Meds
Soc Hx
Fam Hx
MSE
Labs
PE/Vitals

Case formulation: xx year-old m/f presenting to the er with complaint of xxx in the context of yyyy. Likely meets criteria for zzz but a, b, and c cannot be completely ruled out.
Would benefit from brief inpatient admission for diagnostic clarification and optimization of pharmacotherapy in coordination with outpatient services.

Plan:

Done.

The world awards not perfection but those who get **** done. (not to diss perfection, I am much more detail oriented and thorough OP, but in the ER, GET IT DONE)

 

[MysticHealer]

Thanks for the feed back. The 30 min was for a CSV patient: One that I know nothing about before hand other than a name and age a min or 2 before and obsevered by the attending. I guess I'm kind of OCPD and think that my note need to have a flushed out past history to make it easier for the inpatient team. I've also always been kind of a slow and still poor accuracy/ typo typest. Keep the suggestions comming. Thanks

 

[beezley]

You just have the make the best decision you can with what you know at the time. Sometimes the ER cases take awhile and there is no getting around that. But just remember that the world looks a lot different at 2am with the limited info available at that time compared to 9am when everyone is awake. And someone is always mad the next day---but they weren't there at 2am. They were sleeping. Do what the patient needs-even if it means less sleep-do what you would do if they were your family member but try to be efficient. A lot of doing call is figuring out that balance.

 

[Scorcher31]

Interview is a different story, but for the notes 10-15 minutes for any admission/commitment notes, ~ 45 minutes for any discharge note including multipe suicide risk assessments, extremly picky wording and a detailed follow up plan.

 

[BobA]

I think it depends on the patient and situation. But for most general bread and butter ED visits I'd say 45min for interview/getting collateral /talk with attending, and 15min writing up the note.

Also, I'm a fairly fast typist (but not perfectly accurate), but I just can't wrote most of a note during the patient interview. I can fill in the past psych/med/surg/subs abuse/soc/fam psych history just fine. But the HPI, Assessment &Plan I just have to leave alone and write it up later because I feel I need to be able to connect with the patient during those portions.

In medical school they did this thing where they (1)required us to type notes while talking to patients during our family med rotation and then (2) randomly got a patient to sign a release allowing them to record video of the appointment. At the end of the rotation we watched ourselves on video while typing the note in a meeting with the clerkship director. It was horrifying. I thought I was so slick, but I just looked at the computer 85% of the time.

My main hospital let's us use Dragon speech recognition software - and you can use a little recorder in the ED and transfer it into text later. Also, some of the hospitals I work at let us dictate. My dictated notes tend to be much more flushed out. If you're struggling with typing notes, you might look into being able to dictate/use speech recognition software.

 

[whopper]

The only way you can make these notes real real quick is it's is so fracking black and white as to whether or not the patient will be admitted or discharged, and if you really went too fast on it, I could see a doc messing up once in awhile.

Where I'm at, 40 minutes per patient is a very fast speed but IMHO it's because there's too much paperwork involved. Billing, dictating, signing off the med reconciliation sheet, the 72 hour hold papers, admission orders, calling the floor to see if there's a bed open, making sure if the patient has the right insurance for which hospital, signing the medication consent forms takes a long time.

Where I did my training all I had to do was admission orders, a brief H&P, and 72 hold forms and the staff handled the rest. In those situations, if it was black and white I could get it done in 20 minutes on a good day.