Book Rec Request: How to Document Efficiently

[DoctahB]

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Hey All,

Wondering what **book** resources are out there to assist with improving speed and efficiency of documentation. I've seen quite a few paid websites that offer assistance with this but wanted to sink my teeth into a book before considering these paid resources.

An example of a type of book I'm looking for: "Extreme Clinic" - helping to cut down visit times to 7 minutes.

Thank you in advance!

 

[VA Hopeful Dr]

I'm not sure a book is the best way to go about it, nor a paid website honestly. Reason being that everyone does things a little differently. Once you find out how you like to practice, then you look for ways to improve efficiency within your style of doing things.

I'm sure many of us here would be happy to give you some generic tips/ideas that might help but like books will be limited because much of it might not work because of how you practice.

For example: I have a partner who is way more efficient than I am. He pulls this off by using scribes. I hate using scribes (I have in the past) so I'll never be able to see the number of patients he does without hating my day. Another has his nurses do 90% of the HPI for most patients. I don't trust anyone else to do my HPI so that's not an option for me either.

 

[Ironheme]

I agree with VA Hopeful Dr.

One thing that helped me was reading my own past notes and seeing if there was anything lacking. Example - pt here for f/u diabetic visit not well controlled on GLP1, SGLT2 but no metformin. If I had to dig through the chart to find the answer, then that taught me what I should have put in that last note to improve my documentation. Then the next time I'd write: Failed metformin previously due to GI side effects even at lowest XR dose.

It also helps to pay attention to what you're skimming through in other people's notes. That tells you it's not that useful in there and you can likely cut it (assuming you're not being a lazy doc just skimming through everything important...).

 

[door_to_balloon_knot]

I suggest either utilizing your EMR’s text-expander or dot-phrases and setting up common A/P verbiage to be pasted. That way you can just punch in the majority of the stuff you would do routinely and just leave one section to modify your meds/ variables.

Heck, even Google chrome has an extension called Magical text expander and you can create your own. If the task of creating your own seems arduous, just Google for cope paste texts to get started or just create one from a previous note that you were happy with. Each dx in a note take me 30s- 1 minute on average to create with the above plus dictation. I’m a fast typer but make occasional errors and the task of deleting and retyping is sub-optimal for me.