CHarting from home ..taking over my life

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scharnhorst

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Hi
I'm sure most FP docs deal with charting issues a lot but mine is taking over my life

I bring home 40-50 % of unfinished clinic notes every day and if I do not finish same night carries over the next day...2 such days in a row its a disaster on the weekends
so far I'm keeping up but by completely sacrificing my home life , get up super early and chart etc

problem is I get distracted too easily with patients jumping from one problem to another at clinic visits and staff interrupting me with questions and once I lose my train of thoughts very hard to complete the note while seeing the patients
Plus I try to tie up the loose ends of their chronic medical conditions as we have a very high no show noncompliance rate

long been diagnosed with ADD but I dont take meds as I'm afraid state license will be denied or will have to give a long winded explanation for it plus it raises my BP


please advise how I can find a balance , any suggestions are welcome
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I guess it depends on the EMR you are using? They are all different, some worse than others. If it's Cerner - there is no hope. If it's EPIC then I would look at trying to get caught up at lunch, with EPIC the staff should be doing most of the work. You can do the orders, meds, diagnosis, and LOS in the room while talking to the patient. Just finish up the chart body on lunch hour. If it's meditech - 50/50 you will ever get done during the day. Took me almost a year to go from 4 hrs of charting a night to getting out on time. I personally don't chart in the room with the patient, do the minimum to get them out the door and chart in between or when staff is on lunch.

If you get a lunch break then shut your door and chart. I agree that once you get behind it's very hard to catch up.
 
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I don't have ADHD, but I have somewhat compulsive tendencies as far as some things go. I get my notes done while I see the patient. Always have, even before we were on EHR. By the time the patient is checking out, I'm finishing my note and signing it off. After work, I may correct some typos (if any) and fine-tune something, but I'm typically not at the office for more than 30 minutes after closing (unless I'm doing something silly like checking SDN or eBay). And, yes...my typical patient is older, with multiple chronic conditions, so my notes aren't usually very short. I can type 80 words/min. and use a lot of pre-formatted text for the A/P. I've had colleagues follow me around before, and their jaws usually drop when they see how fast I can get a note finished. How? Preparation and repetition. Most of what we do is repetitive. Take advantage of it. I'm also very organized in general about how I practice, so I make sure patients follow up at appropriate intervals, get labs beforehand when necessary, and I'm not afraid to tell them they'll need to make another appointment if they have too much going on to cover in a single visit.
 
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I should clarify that it's not like I don't do anything EHR-wise outside the office. Since I like to start every day with a clean slate, part of my routine is to log into our EHR every AM (with my first cup of coffee) and clear out anything that's come into my inbox since I left the previous day (mostly B.S. automated refill requests and lab/study results). That usually takes me 15 min. or so. Since I'm typically off on Wednesdays, I'll log in Wednesday night (so I have more time) to take care of anything that came in during the day. That might take me 30 min. or so, since there are usually some phone messages and scanned documents along with the other stuff. If I'm on call (a couple of times/month, maybe), I'll log into the EHR from home to document any on-call messages I take. I logged in for about 10 min. tonight, too, since I left at noon and wanted to call a patient back about an x-ray result.

It's all about staying on the crest of the wave, IMO. Procrastination is pointless. Do today's work today. There will be more tomorrow.
 
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Blue Dog said:
I should clarify that it's not like I don't do anything EHR-wise outside the office. Since I like to start every day with a clean slate, part of my routine is to log into our EHR every AM (with my first cup of coffee) and clear out anything that's come into my inbox since I left the previous day (mostly B.S. automated refill requests and lab/study results). That usually takes me 15 min. or so. Since I'm typically off on Wednesdays, I'll log in Wednesday night (so I have more time) to take care of anything that came in during the day. That might take me 30 min. or so, since there are usually some phone messages and scanned documents along with the other stuff. If I'm on call (a couple of times/month, maybe), I'll log into the EHR from home to document any on-call messages I take. I logged in for about 10 min. tonight, too, since I left at noon and wanted to call a patient back about an x-ray result.

It's all about staying on the crest of the wave, IMO. Procrastination is pointless. Do today's work today. There will be more tomorrow.
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Procrastinator here....bane of my existence....but I procrastinate sometimes because I have no idea what to do with a result and have to go look it up....so I put that off until I'm ready...hence work backs up and I'm stuck doing messages/notes for about an hour a night....but notes are different as an attending vs a resident...it'll get better.....
 
How are you able to remember what the patients' complaints were and all the other things they told you as you finish up the charts 6 hours after seeing them? I once admitted only 3 patients and had trouble recalling their H&P's just hours later..
 
SqEdSaint said:
How are you able to remember what the patients' complaints were and all the other things they told you as you finish up the charts 6 hours after seeing them? I once admitted only 3 patients and had trouble recalling their H&P's just hours later..
Click to expand...
Vagueness to the point it's not a liability.
 
I usually leave the office within a half hour of finishing. On days where patients are on time of early it's the easiest. On days where it seems some catastrophe has swept the entire town it's much harder. I finish my notes at the time of visit. I type while speaking with the patient. Most patients are fine with this but I can sometimes feel eyes drilling holes into me when I see patients of my colleagues where this doesn't happen. A quick "I want to type while speaking to you so I don't forget what you tell me" often suffices. If I'm rather far behind everyone knows because there's no music coming out my Dragon mic but rather words going in because I'm dictating.

My notes do not contain superfluous crap. For example, I don't import full imaging reports but rather summarize them. I put labs of importance in my condition summary. It doesn't matter if I put everything in my note regarding data because I'm still responsible for it. Not doing anything about a creatinine doubling isn't justified by "I didn't see it (because I didn't put it in the note)" vs. "creatinine doubled" in my HPI and not doing anything about it.

A lot of my note is completed before going in the room. While my nurse is rooming I pull up my Epic template which importants an F2 for the assessment/plan which I document on the problem list screen and F2 in, the HPI which if for chronic disease management is fairly easy to complete before going in the room sans a few details along with ROS, vitals and PE. I use a smart block for the ROS/PE.
 
Why do more primary care doctors not use medical scribes? Either a contract service or well trained medical assistant to serve in the role?
 
DonKing said:
Why do more primary care doctors not use medical scribes? Either a contract service or well trained medical assistant to serve in the role?
Click to expand...
hi doc i just come in once a year
so i thought id get it all out of the way in one visit
here it goes
viagra refills
L thumb pain
rash on my butt
dizziness
my stomach hurts as I eat too much ibuprofen because I have bad knees
oh and parking placard paperwork
 
DonKing said:
Why do more primary care doctors not use medical scribes? Either a contract service or well trained medical assistant to serve in the role?
Click to expand...
Where I work, the scribe comes out of my RVU production so ultimately out of my salary. I'm not prepared to see 3, 4 or 5 more patients a day to justify a scribe
 
scharnhorst said:
hi doc i just come in once a year
so i thought id get it all out of the way in one visit
here it goes
viagra refills
L thumb pain
rash on my butt
dizziness
my stomach hurts as I eat too much ibuprofen because I have bad knees
oh and parking placard paperwork
Click to expand...

so that's a 10 minute visit -- you want to try one a little harder?
 
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SqEdSaint said:
How are you able to remember what the patients' complaints were and all the other things they told you as you finish up the charts 6 hours after seeing them? I once admitted only 3 patients and had trouble recalling their H&P's just hours later..
Click to expand...

This. The answer, of course, is that you usually end up writing short, crappy notes.
 
DonKing said:
Why do more primary care doctors not use medical scribes? Either a contract service or well trained medical assistant to serve in the role?
Click to expand...

1) Money. I'd rather keep it.
2) Training them is a PITA, and having somebody following you around all day is annoying.
3) When they quit (and they will, 'cause it's a **** job), you're screwed.
4) I'd have to read all of their notes and correct their mistakes. No, thanks.

The free clinic I work at uses scribes. While they're nice kids, their notes are crap.
 
Best thing that has ever happened to my EMR experience is getting a good dictation program. As a matter of fact, I am on it right now and recognizes every word dang near perfectly. Also does a bang up job on diagnosis and medications.

In residency and my first few years of practice, I was pretty bad and was no stranger to note purgatory. Dictation has been a Godsend. My note productivity improved when my exam room skills improved. Redirecting the interrogation when it goes off on tangents that are usually meaningless, time consuming and confusing. The time has to come from somewhere. The extra 5 minutes you spent asking about Cousin Clara's wedding could of been one less note you have to finish up at the end of the day because you're now 35 minutes behind, flustered and rushing. The hard part is redirecting and refocusing without the patient feeling like you're rushing/don't care/not listening. Knowing the right questions to ask and how to ask them. Asking about something personal in their lives that y'all talked about last time goes a long way. "How's that Corvette project coming along?" But keep the small talk to a reasonable level for the time allotted. There's nothing wrong with the small talk while you're doing the PE. You've gotta get that shot clock going in the back of your head.

A lot of this has come from experience and lots of note purgatory pain.
 
Not primary care (PICU actually) and don't have the same time constraints y'all do, but efficiency is a learned skilled

1) use whatever sort of automation you can within your EHR - even for simple things you use all the time, they can be super helpful. In EPIC, taking 20 minutes to create your 15 most common entries to dot phrases can save you a ton of time over the course of days, weeks, months.
2) Stay pertinent - in your notes and in the room - residency programs in primary care rarely force residents in clinic to face the sort of limited time constraints that occur in the real world, and typically reward residents who can dig up the most obscure fact in a history. Forget it, focus on the issues at hand. Don't let patients offer you information, ask questions to get the things you need.
3) Keep in mind your audience - no one is grading your prose - bullet points and lists are totally okay and get your point across. Likewise for specifics of illness durations and such - 3 days or 4? Forget it, just say "several". And for liability, list your medical decision making and what turned you away from a diagnosis as long as it's reasonable - don't list 5 negative symptoms when 3 will do
4) Let go - notes aren't meant to be perfect. As an ICU attending, the note I write at 10a may or may not be the plan by 230p. It's not worth it for me to fret over whether the note is a perfect record of what ended up happening.
5) Stay pertinent - can't say this enough. Realize the limitations of expounding on every single topic. My classic example to my residents for ICU discharge or transfer summaries when I was a fellow was "Patient went on VA ECMO 4/2, decannulated 4/12" and that was all that was really needed. No other providers need more detail than that - not their pediatrician, not their chiropractor, and certainly not another intensivist - unless something totally bizarre happened.

Lastly, if you have a medical condition, be a good patient and get it fixed. We all bemoan when our patients don't take our advice, but then are often hypocrites. Get to your own doctor and see what options are out there for your ADHD
 
mark v said:
Best thing that has ever happened to my EMR experience is getting a good dictation program. As a matter of fact, I am on it right now and recognizes every word dang near perfectly. Also does a bang up job on diagnosis and medications.

In residency and my first few years of practice, I was pretty bad and was no stranger to note purgatory. Dictation has been a Godsend. My note productivity improved when my exam room skills improved. Redirecting the interrogation when it goes off on tangents that are usually meaningless, time consuming and confusing. The time has to come from somewhere. The extra 5 minutes you spent asking about Cousin Clara's wedding could of been one less note you have to finish up at the end of the day because you're now 35 minutes behind, flustered and rushing. The hard part is redirecting and refocusing without the patient feeling like you're rushing/don't care/not listening. Knowing the right questions to ask and how to ask them. Asking about something personal in their lives that y'all talked about last time goes a long way. "How's that Corvette project coming along?" But keep the small talk to a reasonable level for the time allotted. There's nothing wrong with the small talk while you're doing the PE. You've gotta get that shot clock going in the back of your head.

A lot of this has come from experience and lots of note purgatory pain.
Click to expand...

I'm looking into Dragon, what microphone setup do you use?
 
oldanddone said:
I'm looking into Dragon, what microphone setup do you use?
Click to expand...

I don't use Dragon, but one of my partners does, and she uses a Nuance PowerMic. She loves the accuracy. The only thing she doesn't love is the USB cord. It's a nuisance when walking around with a tablet. As a result, she does most of her dictation at her desk.

powermicII.jpg
 
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Currently using a Phillips Speechmike Pro with Fluency Direct software. EMR is Greenway.
 
Blue Dog said:
I don't use Dragon, but one of my partners does, and she uses a Nuance PowerMic. She loves the accuracy. The only thing she doesn't love is the USB cord. It's a nuisance when walking around with a tablet. As a result, she does most of her dictation at her desk.

powermicII.jpg
Click to expand...

can she dictate using a blue tooth microphone?
 
Also want to add.. if you guys are in PP, or dept allows, I would come up with a handout which covers why the patient is here, meds they're on (changes), a brief 12 point ROS that they can check/uncheck, and finally a line at the bottom that says "I will discuss these issues at the follow up visit __________". We have two different ones.. one for new patients and one for established. This will help some of you (i know it helps me), come up with the HPI, acknowledge the ROS etc. which speeds the process up.

PS. Also I also use dragon, with the mic, and it works well. I've set up TONS of templates that makes things easy as well. I.e. "Preventative Health Visit Men", brings up all of the AHRQ based recommendations, counselling. I just delete what I didn't do/not pertinent. Done in less than a minute.. and note looks fancy af. 🙂
 
scharnhorst said:
long been diagnosed with ADD but I dont take meds as I'm afraid state license will be denied or will have to give a long winded explanation for it plus it raises my BP

please advise how I can find a balance , any suggestions are welcome
Click to expand...

Dude. In what God-forsaken omnipotent-government state are you licensed? Are you similarly afraid to be given Versed and Lortabs if you get a tooth extracted? Sad what the credentialing process has- apparently -done to physicians possibly seeking behavioral health evaluation/treatment.
 
Marcus Brody said:
Dude. In what God-forsaken omnipotent-government state are you licensed? Are you similarly afraid to be given Versed and Lortabs if you get a tooth extracted? Sad what the credentialing process has- apparently -done to physicians possibly seeking behavioral health evaluation/treatment.
Click to expand...
Yeah that's crazy - if you're taking meds for a legitimate condition that isn't something like schizophrenia then the boards don't care.

Nice to see you're still around, by the way.
 
So you guys think if I'm taking meds for ADHD I will not have to give long explanation to the boards ? As they ask if you are on any medications that may "affect your performance"
I work in Illinois
 
scharnhorst said:
So you guys think if I'm taking meds for ADHD I will not have to give long explanation to the boards ? As they ask if you are on any medications that may "affect your performance"
I work in Illinois
Click to expand...

If it affects your performance, it will be for the better.

I've prescribed ADHD meds for doctors, and know plenty who take them. It's not a problem.
 
Blue Dog said:
If it affects your performance, it will be for the better.

I've prescribed ADHD meds for doctors, and know plenty who take them. It's not a problem.
Click to expand...

It's only a problem if you snort the contents of your Adderall XR capsule from a hooker's ass while chugging a 750 of Henny.
 
scharnhorst said:
hi doc i just come in once a year
so i thought id get it all out of the way in one visit
here it goes
viagra refills
L thumb pain
rash on my butt
dizziness
my stomach hurts as I eat too much ibuprofen because I have bad knees
oh and parking placard paperwork
Click to expand...

I could handle that in a 15-min. visit easily. I might make him come back about the dizziness if I couldn't figure it out quickly. My staff takes care of the handicap placard forms. I just sign them.
 
Ive seen some FM job offers that boast a 4 or 4.5 day work week....Would catching up on charting on the 5th day and just considering it part of the work week be a good idea?
 
scharnhorst said:
Hi
I'm sure most FP docs deal with charting issues a lot but mine is taking over my life

I bring home 40-50 % of unfinished clinic notes every day and if I do not finish same night carries over the next day...2 such days in a row its a disaster on the weekends
so far I'm keeping up but by completely sacrificing my home life , get up super early and chart etc

problem is I get distracted too easily with patients jumping from one problem to another at clinic visits and staff interrupting me with questions and once I lose my train of thoughts very hard to complete the note while seeing the patients
Plus I try to tie up the loose ends of their chronic medical conditions as we have a very high no show noncompliance rate

long been diagnosed with ADD but I dont take meds as I'm afraid state license will be denied or will have to give a long winded explanation for it plus it raises my BP


please advise how I can find a balance , any suggestions are welcome
Click to expand...

I used to have the same problem. Now I take my laptop to each patient encounter and type the note as I am talking to the patient. It helps that I type fast and don't need to look at the keyboard.

I finish 80% of the notes before seeing another patient (sometimes I go to my office and finish the note).

If run a little behind that's fine. I'm not sacrificing the time that I am supposed to share with my family because of this.
 
PlutoBoy said:
I used to have the same problem. Now I take my laptop to each patient encounter and type the note as I am talking to the patient. It helps that I type fast and don't need to look at the keyboard.

I finish 80% of the notes before seeing another patient (sometimes I go to my office and finish the note).

If run a little behind that's fine. I'm not sacrificing the time that I am supposed to share with my family because of this.
Click to expand...

Has this affected your ability to interact with patients?
 
Sardonix said:
Has this affected your ability to interact with patients?
Click to expand...

Not really. If it is a new patient I usually say something like "I am sorry but they make us do everything in the computer nowadays" and "Sorry for the computer but I am just making sure that all of the orders are in before you leave so we don't miss anything".
 
I made it a point in residency to get efficient enough to get the note 90-95% done by the time I saw the next....would stay and extra 30-45 minutes to finish up the rest at the end of the day. Was able to eat dinner with my wife nightly and play some hockey 2-3 times per week.
 
Questions from a pre-med: To the responders:
1) Do you guys bring home any work?
2) Do you guys stay in the office past closing time?
3) How long have you been practicing FM?
 
GoofyPaw said:
Questions from a pre-med: To the responders:
1) Do you guys bring home any work?
2) Do you guys stay in the office past closing time?
3) How long have you been practicing FM?
Click to expand...

1) No.
2) Not long (typ. <30 min.)
3) 16 years.
 
GoofyPaw said:
Questions from a pre-med: To the responders:
1) Do you guys bring home any work?
2) Do you guys stay in the office past closing time?
3) How long have you been practicing FM?
Click to expand...

1) No
2) No
3) IM. Little over three years.
 
1. Rarely
2. Usually. My practice is currently growing like gangbusters with the loss of a local fam doc. I'm seeing 6-10 new patients a day. I'm leaving by 5:30 ish each day.
3. FM: 8 years. Private practice year 5.
 
I would never leave the office without all my charts signed off save for extenuating circumstances. Why? They'd never get done, at least never accurately.
I even try to finish most of my notes as soon as I finish seeing the patients. I might let 2-3 stack up, maximum, for doing at the end of the day if they are complicated charts. Right after I see my last patient around 4:30 or 5, I sit down, and bang out those charts. No exception. I'll spend 30 minutes usually, and then go home at 5:30 or 6:00pm.
People who don't finish charts invariably are not doing it correctly. In my experience, usually it's over-charting. You need to look very closely at the requirements for regular office visits. A quick follow up appointment can be billed as a 99213 and completed in 2-3 minutes. A 99214 visit with 3 chronic stable problems can be charted in 4-5 minutes easily if you have a good system down. You should NEVER write big long paragraphs repeating large amounts of what a patient told you during a visit. The HPI should be bullet pointed, with the minimum number of elements for each problem to reach the desired coding level. Only if you have a real medical mystery on your hands should you go into detail. Save the verbosity for your assessment and plan.
When you finish seeing the patient, sit down and pick the problems you addressed. Add them to your document. Systematically go through and write a CONCISE one liner about each problem and what the plan is. If they have a complicated issue, sure, spend a couple extra minutes making the A&P very clear. But just get it done and move on.
 
Dragon Medical One (with the mobile app to use my iPhone as the powermic) has been great for our organization. I find it is pretty darn accurate out of the box and I am able to complete my Epic notes in a timely fashion as long as I document elements of the HPI and PE in my note. If I have all my orders in before the patient leaves then the documentation takes about 2-3 minutes to finish up. Compared to most, I probably overchart but I find that leaving myself details for what to do on the follow up visit in my A/P section shortens my follow up visit time by providing a focused agenda.

GoofyPaw said:
Questions from a pre-med: To the responders:
1) Do you guys bring home any work?
2) Do you guys stay in the office past closing time?
3) How long have you been practicing FM?
Click to expand...

1) Yes but admittedly I have multiple roles (Family Med/Clinical Informatics)
2) Sometimes 30 minutes after but mainly to follow up on results/patient calls on my clinic days.
3) FM - 6 years post residency

Blue Dog said:
My staff takes care of the handicap placard forms. I just sign them.
Click to expand...
I dream of the day Handicap placard forms and FMLA forms are automagically filled out for me requiring only a signature. 😉
 
I'll echo what was said above. Just say no to the note manifesto. You're doing much more work for ZERO additional compensation. Happy patients, good care and hopefully profitability is the ultimate goal. just enough to give you a good idea with the patient encounter was about. keep things relevant. keep the interview move forward. The patient's grandson's bad marriage unfortunately, is not something you can bill for.

In residency, I really struggled with completing my notes in a timely manner. What I came to realize that note completion was a symptom of a larger problem. Time management. I had to develop a shot clock in my mind to get me in and out of the room while also covering what needed to be covered, and have patients feel like you're being thorough and not rushing them out the door.

I take work home in the form of being on call during the week but it is minimally intrusive. My notes are almost always complete as the patient is walking out of the front door.
 
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Get a scribe or start doing better agenda setting and negotiating what's going to be addressed. Document less 'crap' and more pertinent, refined information. Read some articles about setting the agenda of the visit. Don't room patients who are >__ min (choose time) late for their appointments. I'm molding my population into being 'good patients' by educating them about how to best interact with our clinic: e.g., med refill requests through the pharmacy only, use the patient portal for minor questions and normal lab results, only can address X number of problems in 15 min otherwise need to request more time when being scheduled, etc.
 
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