charting at bedside

[BAM!]

With flu season in full swing and subsequent increased patient loads, I've been falling behind on my charting. Anybody chart at the bedside with a laptop? How about something cheap like the HP Stream?

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[gutonc]

No computers in your rooms?

 

[ERDude]

Scribes.

 

[WilcoWorld]

I often chart at the bedside, but not when I think the patient has the flu!

 

[Old_Mil]

When it comes to computers, like most things, cheap and good usually don't coexist. You can get a 11-12 inch screen laptop and carry it around or a surface pro 3. I would recommend something fast and responsive or the benefits will be.lost. If your EMR has an android or ios app, you can consider an ipad or android tablet. Get one with good specs (quad or octa core). Otherwise you will be connecting through something like Citrix. Get horsepower-i5/8gb of ram.and a 500gb SSD are minimums.

This will only work as well as your hospitals secure WIFI so keep that in mind. If the network is a bottleneck it won't work well at all.

Finally, some EMRs are more point and click than others. Some require you to type a lot of numbers. If yours requires a lot of typing you may be better off with a laptop because there.is an efficiency loss involved in pulling up and minimizing the virtual keyboard on a tablet.

Bedside Charting/CPOE Advantages: A more accurate, defensible, billable chart filled out at the point of care, easier to chart billable things like cardiac monitor readings at the bedside, it smooths out rad/lab/nursing orders so that people.down stream aren't getting hit with 3 or 4 patient boluses at once. Overall the ED runs better this way, I think.

Bedside Charting Disadvantages: You are going to be looking at the screen while the patient talks which may result in a patient satisfaction score hit. You do spend a little extra time with each patient (which may at least partially counteract the satisfaction score hit). To quantify it I average about 10%-15% slower than my non bedside charting colleagues (.2-.3 PPH) but my charts are much more thorough (for instance, my ROS is always has positives selected and negatives struck through vs the generic neg except for HPI for all organ systems). My absolute maximum rate to see patients is probably. a bit lower so if five people walk in at once it is going to take longer to get around to seeing patient five. If you live and die by door to doc times this may be an issue. The flip side is once I see patient five I just keep going and don't have to.retreat to the bullpen to chart and order stuff.

 

[engineeredout]

Problem I see is the longer you're in the room, the more complaints seem to develop. "Oh by the way I've had this toe tingling for 15 years that has been evaluated by my PCP, Johns Hopkins, Cleveland clinic, Neurosurgery, three psychiatrists, endocrine, and the top dermatologist in the country, but since you're here..."

 

[BAM!]

No computers in my ED's private rooms. Lots of curtain rooms. The reason I posted the original question is that sometimes I chart at home and I have a ton of hotkeys set up through 3rd party software. I can't access these hotkeys from my hospital's desktops. We have dragon, but I find that keyboard hotkeys are faster and more accurate even than Dragon presets. No, we don't have EPIC.

Also, EMR's are not that processor intensive, so I imagine the wifi network would be more of a limiting factor. My chromebook is quite speedy (but lacks capabilities of a windows OS). I'm not sure how quick the new streams (cheap windows based laptops) are, but that's sort of what I was getting at.

I'm not too worried about the "zillion complaints" that arrive from charting in the room. the more complaints you have, the less likely it's something serious. And if it is, there usually is some objective data that points you in the right direction.

 

[BAM!]

Also, we have scribes. They are helpful during periods of surge. But honestly, I think I can get my charts done faster without them.

 

[RustedFox]

With regard to "complaints about charting in the room"; as long as you don't make it seem like you're completely ignoring the patient and instead checking your facebook posts - it shouldn't be a real problem. A few simple words go a long way, like; "I want to make sure that I get this all down right, and get it right the first time, so let me get this in here right now while its fresh in both of our minds".... or something to that end. Don't make it seem like you're simply the voice on the other end of the drive-thru asking if their pain is "sharp or dull".

 

[Alvarez13]

I feel I could get orders in faster if I just did them in the room with the patient, then on to the next patient instead of seeing a few then going back to the center to do all the computer work. I feel everything would move faster the sooner you get the labwork in and the sooner they start drinking that contrast. Plus, I won't have to try and memorize last menstrual periods and other annoying specifics.

Too bad out ED's wifi sucks balls!

 

[DeadCactus]

I feel I could get orders in faster if I just did them in the room with the patient, then on to the next patient instead of seeing a few then going back to the center to do all the computer work. I feel everything would move faster the sooner you get the labwork in and the sooner they start drinking that contrast. Plus, I won't have to try and memorize last menstrual periods and other annoying specifics.

Too bad out ED's wifi sucks balls!

Tangential but are your patients really drinking contrast that frequently?

 

[RustedFox]

Tangential but are your patients really drinking contrast that frequently?

Yes. They are. Especially if they're over 55 with abdominal pain and... are an American. With an American diet, and an American attorney.

 

[DeadCactus]

Oral contrast is a rare event where I am. IV only for the vast majority of abdominal pain. I'd thought PO contrast was globally moving out of favor but maybe it's a regional variation...

 

[RustedFox]

I feel the need to expound upon my last post:

If you've got a complaint of abdominal pain, and suspicion for any 'honest-to-God' GI related pathology.... oral contrast can make a huuuge difference. Nevermind the fact that your radiologists are invariably and reflexively going to state in their report "the lack of oral contrast limits assessment of the GI system" - but I have seen several dozen (no exaggeration) "bounceback" cases where Dr. Homeboy discharges patient after acute abd. series... then they get to me. I take some time and listen to the history, order full IV/PO contrast CT, and boom.... Crohn's Disease/Colitis NOS, enhancing (metastatic?) lesion here or there, some weirdo fistula or Zlolzers divertculum... and it goes on from there.

At all of my job sites, we're getting top-down pressure to forego oral contrast in general to "cut down the times". Sure, I get it - your garden-variety appy-ies (sp?) dont need contrast, but there are a good, good MANY of those who seriously benefit from an otherwise no-harm intervention (save bull$hit allergies) that really does change the course of their care.

Do the right thing for the patient.

 

[TooMuchResearch]

I tried some in room HPI writing today. Granted, I expect it will take practice to make it work, but I wrote a longer HPI that was not more helpful, and I couldn't remember any of it during my sign out to the hospitalist since I didn't have a reason to keep it in my brain. On another one, the patient and girlfriend definitely watched me open my note template that auto-populated PMH including erectile dysfunction and STIs. Then I went back to my comfortable 1-2 minute HPI after my evaluation.

 

[bougiecric]

Do the right thing for the patient.

Aw, come on man. I generally appreciate your posts, but this a bunch of anecdote punctuated by patronizing.

There's variation in practice, yes, but certainly no good evidence that oral contrast significantly improves diagnoses in abdominal scans.

I can add my anecdote that I've never had a bounceback due to lack of oral contrast.

 

[deleted109597]

At all of my job sites, we're getting top-down pressure to forego oral contrast in general to "cut down the times". Sure, I get it - your garden-variety appy-ies (sp?) dont need contrast, but there are a good, good MANY of those who seriously benefit from an otherwise no-harm intervention (save bull$hit allergies) that really does change the course of their care.

Do the right thing for the patient.

No, no no no nononononononono.
This is another one of those things where practice pattern trumps actual science.
http://www.epmonthly.com/features/current-features/contrast-is-unnecessary-for-most-abdominal-cts/
http://blog.ercast.org/requiem-oral-contrast/

 

[Doctor Bob]

If your radiologist needs PO contrast to find clinically significant Crohns, diverticulitis, or other intestinal wall pathology, then you need a different radiologist.

The scanners are getting better and better and the image resolution is improving. IV contrast I still give... but PO? Practically never.

 

[e30ftw]

At all of my job sites, we're getting top-down pressure to forego oral contrast in general to "cut down the times". Sure, I get it - your garden-variety appy-ies (sp?) dont need contrast, but there are a good, good MANY of those who seriously benefit from an otherwise no-harm intervention (save bull$hit allergies) that really does change the course of their care.

Do the right thing for the patient.

Disagree.

Our radiologists completely abandoned oral contrast 3 years ago in our routine abd/pelvis CTs and we have had no significant change in our sens/spec of abd CTs for acute abdominal pathology. I have not seen any recent literature to support the routine use of oral contrast in Emergent CT abd/pelv imaging.

Changes a 6 hr dispo to a 2 hr dispo and imo ordering IV only contrast is "the right thing for the patient." Unless they have a single transplanted kidney.

Re: charting at bedside: I never chart at bedside. I spend a short amount of time in the room and devote it 100% to the patient. I sit down when able, look them directly in the eye and ask them pointed questions about their visit which I remember in my head, walk out, put in orders and write the doctors note/MDM right after patient encounter then do the chart later if I don't have time.

 

[future_dr_house]

We use scribes, so I devote full hpi time to listening and then as I go over allergies, pmh, etc I log in to "make sure what we already have is correct" which I do but I also add orders then scan for new patients. Then phys exam, exit and dictate my findings to scribe en route to the next room. What slows me down now is heading back to the main physician room for discharges. Our scribe puts in dx and dc info that we dictate. I will get rx ready and then head to the room for the update with printed labs and rads to hand to them.


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[turkeyjerky]

3rd year resident here. My preferred workflow is to see 1 pt, then go to the charting room, put in orders and dictate my note using dragon rinse wash, repeat. Most of the time, I end up seeing a patient, putting in orders in the charting room then having to go see the the next 2 patients I've been slotted during that timeframe. I catch up my notes when I have a few minutes here or there later in the shift. Once in a while, if I come in and there are 4-5 to be sleen or I'm slotted an equivalent amt I'll log in to the computer in the room and chart a barebones HPI and PE while talking to the patient and put in orders before I leave. I don't really like in-room charting as I find that I am more focused on the computer than the patient and and logging into the system is a big timesink. It is nice to be able to review old records while in the room with them though (no ma'am, vomiting after oysters one night does not mean you have an "iodine allergy"; so is your abdominal pain today similar to the pain you had that you came in for last week and had negative labs, CT and ultrasound?)

 

[Old_Mil]

...and... are an American. With an American diet, and an American attorney.

Basically describes 99% of what we do.

 

[RustedFox]

Okay, I'll respond to the argument. I can be wrong, too - but when I order a plain-vanilla CT, often, the first two sentences of the report are often (seriously) "The lack of oral contrast limits evaluation of the hollow organs. The lack of IV contrast limits evaluation of the solid organs." Maybe we do need some non-curmudgeon radiologists. Combine that with Old Mil's statement above, and its easy to imagine a situation where you have to answer the question "Why didn't you use contrast when ordering the scan, doctor?" The answer can't be: "Well, to keep the throughput times down." And yes, I have seen bouncebacks where the second, contrasted study reveals the pathology at least a few times. Maybe the disease hadn't fully presented itself fully. I'll have to keep these things in mind as I move forward.

I'll say this. I play golf regularly with my radiologist at one of my job sites and we frequently discuss matters like this. His bone to pick is CT/LP for SAH, in particular - but the sentiment in general related to me (his words) is: "Rusted.... when you CAN use contrast, DO use contrast. The study will be of better quality."

 

[Hair Police]

Okay, I'll respond to the argument. I can be wrong, too - but when I order a plain-vanilla CT, often, the first two sentences of the report are often (seriously) "The lack of oral contrast limits evaluation of the hollow organs. The lack of IV contrast limits evaluation of the solid organs." Maybe we do need some non-curmudgeon radiologists. Combine that with Old Mil's statement above, and its easy to imagine a situation where you have to answer the question "Why didn't you use contrast when ordering the scan, doctor?" The answer can't be: "Well, to keep the throughput times down." And yes, I have seen bouncebacks where the second, contrasted study reveals the pathology at least a few times. Maybe the disease hadn't fully presented itself fully. I'll have to keep these things in mind as I move forward.

I'll say this. I play golf regularly with my radiologist at one of my job sites and we frequently discuss matters like this. His bone to pick is CT/LP for SAH, in particular - but the sentiment in general related to me (his words) is: "Rusted.... when you CAN use contrast, DO use contrast. The study will be of better quality."

Hold on. Earlier in the thread you talked about PO contrast, about which there is some decent literature to show it's major function is to constipate your ED, and only minimally adds to the study.

In this post you're talking about non-con CTs, which I think the majority of us would only use in patients we suspect are suffering from nephro-/ureterolithiasis. Nobody is talking about forgoing IV contrast for undifferentiated abd pain.

 

[RustedFox]

Hold on. Earlier in the thread you talked about PO contrast, about which there is some decent literature to show it's major function is to constipate your ED, and only minimally adds to the study.

In this post you're talking about non-con CTs, which I think the majority of us would only use in patients we suspect are suffering from nephro-/ureterolithiasis. Nobody is talking about forgoing IV contrast for undifferentiated abd pain.

Good and valid point. The general idea I'm after here is "optimizing the study". Even in those with 'undifferentiated abd.pain', I've seen contrast make a difference. Maybe I've just got wussy radiologists. Maybe I work in a place where my average patient is 65+ years old and has had every internal organ removed and has a high incidence of malignancy. When you see 15+ Betty White Belly Pains per shift, and they're all status post appy, hyst, chole, colon resection, ostomy, etc. - the contrast might count.

 

[Old_Mil]

Okay, I'll respond to the argument. I can be wrong, too - but when I order a plain-vanilla CT, often, the first two sentences of the report are often (seriously) "The lack of oral contrast limits evaluation of the hollow organs. "

That's the problem. As unscientific as that statement is, medicolegally it hangs you out to dry.

 

[link2swim06]

Hold on. Earlier in the thread you talked about PO contrast, about which there is some decent literature to show it's major function is to constipate your ED, and only minimally adds to the study.

In this post you're talking about non-con CTs, which I think the majority of us would only use in patients we suspect are suffering from nephro-/ureterolithiasis. Nobody is talking about forgoing IV contrast for undifferentiated abd pain.

Furthermore, there is even evidence that PO contrast is harmful and misleading in certain circumstances.

They went through a paper on EM:RAP that showed the PO+IV contrast caused radiologists to over call appendicitis and led to an increase in the negative appy rate.

I guess if you are concern about a perf or you just want to relieve their constipation then have them drink a bunch of gastro.

 

[RustedFox]

Okay suckers: I'm at work right now, and just got back a read for appy in a 7 year old female: IV only contrast given.

Right freaking here, first line:

"Bowel: Evaluation limited without adequate IV or oral contrast present. The appy is not definitively identified. No free air identified."

And again in the summary:

"Limited exam due to lack of PO contrast. Appendix not clearly visualized."

... and yes, I ordered the IV contrast. Limited idea about what she/he means about adequate IV contrast.

 

[xaelia]

... and yes, I ordered the IV contrast. Limited idea about what she/he means about adequate IV contrast.

Sounds like your medical director needs to take it up with radiology why they can't perform a routine, diagnostic, IV contrast CT.

 

[BoardingDoc]

Agree with xaelia, this sounds like a problem with your radiology department and whoever is protocoling the IV contrast. If they aren't giving it correctly, that's on them, not on you.

 

[RustedFox]

Fine by me; but I'm not making this $hit up. Radiology still balks at reading a lot of non-oral contrast CTs.

 

[future_dr_house]

I don't think I'd order a ct for a kiddo without oral contrast. They're too thin and I wouldn't want to radiate them without giving them the best chance to identify the appendix. If they are beefy with plenty of fat then I wouldn't care. Non of my radiologists state that the eval is limited without oral contrast.


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[e30ftw]

our children's hospital seems pretty conservative with radiation and we do peds r/o appy abd/pelv CTs w/ IV contrast only.

the PEM stance seems to be that the reduced specificity of oral contrasted scans (ie, too many negative appendectomies) overrules the "no-benefit" of adding oral contrast.

 

[Hercules]

Fine by me; but I'm not making this $hit up. Radiology still balks at reading a lot of non-oral contrast CTs.

This is an issue with the quality of your radiologists. If every other radiologist in the country can read it but yours, then they are putting you at a serious disadvantage. Imagine if your lab could only give results on troponins if they took 6 hrs to run them. You would rightfully throw a fit. This is no different. Your radiologist are an outlier on the poor end of the spectrum. It's not your fault and you have to play the hand your dealt, but your director should start turning up the heat on getting some qualified radiologists into your facility. Look at the literature. It's not really questionable on this topic. Oral contrast is not a necessity for evaluating the appendix unless you have an extremely low body fat patient. This is not up for debate and if they are refusing to comment on the appendix without contrast they should be replaced by their more qualified counterparts.