Charting question.

[RustedFox]

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General question for the other attendings:

It takes me time to do my charts. I'm very thorough; and when I get interrupted by an RN/MLP/whatever, it really puts me behind. I regularly have charts from 1-2 shifts ago that I'm catching up on during my next shift. My medical director regularly freaks out on me, saying that its a "huge liability!" etc. etc. etc.

I fail to see how its a huge liability. The charts that I "leave undone" are my low-acuity ones which are your basic ankle sprain/cough n cold/whatever visits. Hard to prove negligence on these "level 3 and below" visits.

Am I missing something big here ?

 

[Rendar5]

If it's EMR, these sniffle type patients will sometimes come back and then it's hard to see their prior presentation. I've done the same thign as you before, but doesn't mean I should.

 

[RustedFox]

Yeah, there's that - but the way my director talks to me, you'd think I was committing a cardinal sin. I'm just wondering if he's just cracking the whip, or if there's some giant unforseen danger here that I'm willfully ignorant of.

 

[Daiphon]

Yeah, there's that - but the way my director talks to me, you'd think I was committing a cardinal sin. I'm just wondering if he's just cracking the whip, or if there's some giant unforseen danger here that I'm willfully ignorant of.

Not that I can think of, unless your director means the "liability" he has to admin to ensure rapid completion of charts for next-day billing.

I think as long as all your admitted & sick charts are done, the occasional chart that falls through the cracks isn't a problem.

Plus, if inpatient docs get 7-30 days (the range based on the places I work), I can't imagine any MedMal liability from a 48h delay.

Sent from my DROID BIONIC using Tapatalk

 

[gman33]

I wonder if the "liability" is that you will be out of a job if this consistently irritates the medical director

 

[RustedFox]

I wonder if the "liability" is that you will be out of a job if this consistently irritates the medical director

Thanks for looking out for me - but right now, I'm in a secure spot. If you were here working with me, you'd shake your head and say - "maan, I dont' know how you guys do it with so little staff."

Its far beyond ridiculous at this point, though - it is now impossible to "see them all within 20 minutes", see to nursing staff's every need, supervise 2 MLPs, and do all charting in a realistic time-frame.

You can't create or destroy time.

 

[OCDEMS]

You can't create or destroy time.

The internet accepts your challenge and raises you SDN.

 

[RustedFox]

Destroy. Not waste.

🙂

 

[emergentmd]

There is a liability. I will irritate other docs who happen to see your patient without any records of the first visit. It irritates admin, which then bugs your director.

If everyone was late on charts, no biggie. If you are the only one behind, then you need to find a way to fix this. Never be an outlier.

Being an ED doc, you can't act like an internist. I have been at this for over 10 years and I can finish a chart either by dictating or T system in 2-3 minutes.

Even on days that I saw 30 pts, didn't do a lick of charting b/c it was so busy, I could knock those 30 charts out in 90 minutes. My charts are very complete and never have any billing issues. You just have to figure out this out. It will save you alot of headaches, improve your quality of life.

It pains me to see docs stay 3 hrs after their shift to finish charting.

 

[RustedFox]

I don't disagree.

Sadly, its all of us that are staying 2-3 hours late after hour shifts to finish charting. I'm 1-2 DAYS behind.

Admin here is so unrealistic. They recently tried to 'improve' our situation by putting a midlevel in triage so as to "capture" the timestamp at the earliest possible moment. Sadly, the midlevel in triage has the power to see patients herself, but... doesn't. Because... well, why SHOULD she HAVE to ?

a;dsklfj

 

[em1234]

I get the same thing from my medical director, and he points out it is just a billing issue.

In my hospital I see patients primarily and then I staff and see all the mlp pts. I have come to the resolution that I will finish the charts for all the patients that I see primarily, as to avoid the frustrating endeavor of looking a patient's chart who the nurse tells you was here yesterday only find a blank chart. But for the MLP's charts that I have to attest and sign off on, I'll let those sit around a 5-7d for a night shift to roll around and do 30-50 of them that night.

As I see it: The patient care is covered, docs treating my patients when they bounce back know what I did and what I was thinking, and if we get our money 5d slower, so be it.

-1234

 

[EM_Rebuilder]

You need a scribe.

Nothing has made my work balance better than does a scribe.

They do my notes, go ask where the urine is, call the lab as to why the blood is not back, grab me lunch, etc.

I assure you I am more productive because of the scribes; me seeing ONE more patient per shift MORE than pays a scribes rate.

Good Luck.

 

[RustedFox]

I've pitched this idea to the powers that be already. I even said - "You could either pay a scribe, or continue to pay me for all the time I spend charting."

a;dfsklja;sdfj;aldfj

 

[MSUSpartan642]

How do you guys see 30 patients in a day and then chart at the end of the shift? Do you solely rely on memory for each detail of the note? Seems like a recipe for disaster, aka forgetting minor details that become important. Maybe I'm just still very inefficient.

 

[RustedFox]

How do you guys see 30 patients in a day and then chart at the end of the shift? Do you solely rely on memory for each detail of the note? Seems like a recipe for disaster, aka forgetting minor details that become important. Maybe I'm just still very inefficient.

I remember what rooms these people were in and who they were with. If I forget a detail, the RN notes generally jog me to where my own memory takes over.

 

[deleted109597]

The problem is that many people learn this bad habit in residency (ie, go see the patients and don't chart). You should try to keep at least a partial chart done, and fill it in if you need. Staying behind hours after your shift is beyond comprehension. You're allowing yourself to be bullied into seeing more patients than you can effectively see and chart for.
I would argue that you either pay your own scribe (which isn't a bad idea, actually), or start doing your charts as you go. Too bad if your volume drops. It won't be any worse than staying after for no volume.

 

[RustedFox]

The problem is that many people learn this bad habit in residency (ie, go see the patients and don't chart). You should try to keep at least a partial chart done, and fill it in if you need. Staying behind hours after your shift is beyond comprehension. You're allowing yourself to be bullied into seeing more patients than you can effectively see and chart for.
I would argue that you either pay your own scribe (which isn't a bad idea, actually), or start doing your charts as you go. Too bad if your volume drops. It won't be any worse than staying after for no volume.

Yeah, this.

Trick is, out of five of us full-time docs, there's only one who doesn't stay afterwards to chart. Every single one of us does because we have a mandate from "management" that a patient simply cannot wait for more than 20 minutes - and if our "average wait time" gets above 15... then we get a phone call.

We're quickly getting sick of this.

 

[The White Coat Investor]

I agree that this is kind of a bad habit you've picked up along the way. The fact that your director is bugging you about it is a big red flag.

Now, it's possible this is just a "megatoxic" hospital and needs to have more doctors on. It's also possible you should hire a scribe out of your own pocket to improve your quality of life. But let me explain this to you like I explain it to the mid-levels I work with.

The difference between me and the mid-levels is this. I get paid by the shift (a variable rate depending on what we collect as we're a democratic partnership). The mid-levels get paid by the hour, including hours spent after the shift charting. I don't get paid to stay late and chart, but they do. What are the incentives? To stay late and chart. If you had to use your own time to chart (i.e unpaid time) you'd do it on shift and see fewer patients.

Maybe that's not the issue and I made a bad assumption, dunno.

The other way I look at it is that for every patient I see, there's a certain amount of work I must do. I must do an H&P, order tests, interpret tests, chart, do the discharge paperwork, close the loop with the patient, and perhaps contact a consultant. No matter what order I do the work in, there's the same amount of work. So, barring a life threatening emergency, why not do the work in the order in which I am most efficient? For me, that seems to be do the H&P, order tests, do all the charting except how the patient feels at discharge, and the dispo, then move on to the next patient. When test results come back, I close the loop, finish the chart, and do the discharge papers. Then I move on to the next patient. So I only deal with any given patient twice (maybe 3 times if they're complicated). No constant bouncing around between patients. All charts done before the patient leaves the department. I don't discharge a patient whose chart isn't done.

Now, occasionally some departments get so busy you truly cannot do it this way, but if you try it, you might find those times are actually far more rare than you think, and certainly not a daily occurrence.

Two days behind? There's no way I could remember all those patients. At that point you're just making crap up on the charts or you're writing down notes to jog your memory and essentially doing your work twice.

Good luck, hope you find a solution.

P.S. You said one of you isn't staying late. Go ask him what he's doing and start doing it.

 

[RustedFox]

Thanks for the input.

The one guy who ISN'T staying late... yeah, you should read his charts. Not good. I've seen his bouncebacks, I've caught his mistakes. Not ones I'm looking to make myself.

I do get paid hourly, so there is a small incentive to "spend another hour charting". However, that's time that I'd rather just "not be there".

Now, I admit that I can maybe "sit down and hammer thru it" before going on to a 'next step', yeah - but the attitude here is that "nothing can wait". When you say - "barring a life-threatening emergency, why not...." - it's going to be tough to apply in this situation. The one thing that I think is contributing big-time is the fact that we were once a 20K/year shop that is now on-pace for 26k/year, and the step-up in volume is maddening. Management has tried to give us a 'provider-in-triage' system to try and alleviate the workload, but it is only so effective, especially now because instead of one midlevel to supervise, we now have 2-3 that are starting half-assed workups and asking me to make every decision for them. While it 'captures the timestamp' rather well, its also only there for so long - and its not always there when we simply need "more hands on deck".

Don't get me wrong, I'm not looking to 'blameshift'. I can improve, yes. But its going to take a serious analysis of "whats getting in my way".

Edit: I really do remember every single one of these patients, even 2-3 days later. I remember the strange things they said, who they brought with them, which ones had bad breath, what baseball jersey the kid had on, which old man gave me a golf course recommendation, etc.

 

[la gringa]

i struggle w/ similar issues... i am often complimented on my thoroughness and i rarely have bouncebacks. i also rarely leave on time. i feel like i can't win and my group won't schedule any overlap in shifts 🙁 sighhhh...

 

[la gringa]

Edit: I really do remember every single one of these patients, even 2-3 days later. I remember the strange things they said, who they brought with them, which ones had bad breath, what baseball jersey the kid had on, which old man gave me a golf course recommendation, etc.

so do i, for the most part... if it's a totally generic c/o i HAVE to chart right away or i won't remember.

to the med students and interns/residents - you will be amazed at what you can retain over time about the patients you see. your brain just learns to absorb what you need to know. amazing.

 

[dotcb]

I won't leave 'til I've completed my documentation for the shift. I did this in residency and I do it as an attending. When I go home, I want to forget about what happened and move on, walk into my next shift fresh and not have things "up in the air." I've also seen M & M cases where patient bounces back in a few hours and the chart from visit #1 is blank or woefully incomplete. Then the chart for visit #1 is completed after the patient has died. Looks pretty bad.

 

[Birdstrike]

General question for the other attendings:

It takes me time to do my charts. I'm very thorough; and when I get interrupted by an RN/MLP/whatever, it really puts me behind. I regularly have charts from 1-2 shifts ago that I'm catching up on during my next shift. My medical director regularly freaks out on me, saying that its a "huge liability!" etc. etc. etc.

I fail to see how its a huge liability. The charts that I "leave undone" are my low-acuity ones which are your basic ankle sprain/cough n cold/whatever visits. Hard to prove negligence on these "level 3 and below" visits.

Am I missing something big here ?

Yes, you are missing something. The main crime here is that you're working for free. You're spending time, days later, charting off the clock! Knock it off. You are effectively giving yourself a pay cut: working 12 hr, getting paid for ten.

The part you are obviously not missing is that you are being expected, once again, to do the impossible: see more, better, faster, safer, more efficient, more "satisfied", in less time, with less liability, with half the time that you need.

Been there, done that.

In the words of Bill Clinton, "I feel your pain."

 

[Zanegray]

Many at my shop including myself struggle with the same charting issues. We have a new EMR with "Dragon" voice recognition - anyone else have this? It doesn't recognize schmidt. Editing takes UNTIL FOREVER. (Sandlot anyone?)

Anyway... Rusted - I know that your management is saying that the patients "can't wait" but why not? I think you have to start thinking of the chart as something that can't wait. Its just part of the patient care. If their wait times lengthen because of this, well, they need more docs. But of course this is easier said than done. This is what I'm working on. Some days are better than others. Also - if you do/complete each chart as you dispo its only really 4-6 minutes more? If you wait until the end its a ton of time.

Of course, if no one else is doing this then it messes with your RVUs if your pay or incentive is at all based on that. But I also figured that if I bill for all the time I actually work I make about what the incentive has been - guaranteed. Incentive is not guaranteed and they hold all kinds of other things over your head to get this too.

Anyway - many are with you I think. Who are we kidding. Most of us just need more docs. But a scribe would be a start.

 

[RustedFox]

I know. I figure I have to start saying "this chart cant' wait". But I seriously overheard a phone call the other day with this sentence uttered:

"We're not all that busy today, we've only seen XX patients... so why are we up to 17 minutes on our wait times ?"

Nevermind the fact that we saw nothing between 6 and 9:30 AM, then got murdered with squads and walk-in who were.... gasp... actually sick.

Can't let those patients wait. Just can't.

Those 4-6 minutes that you speak of... well... do TWO of those in a row, and you're now up to 12 minutes on your wait time... add to that the fact that the triage nurse had the audacity to take 5 mintues to do a "good job" and now, you're at 17 minutes ! Inexcusable !

 

[EM2BE]

I know. I figure I have to start saying "this chart cant' wait". But I seriously overheard a phone call the other day with this sentence uttered:

"We're not all that busy today, we've only seen XX patients... so why are we up to 17 minutes on our wait times ?"

Nevermind the fact that we saw nothing between 6 and 9:30 AM, then got murdered with squads and walk-in who were.... gasp... actually sick.

Can't let those patients wait. Just can't.

My intern year I felt pushed to see more patients than I could handle. Because of this, I started charting at the end of a shift. One day, I had enough. I decided to chart as I went along with exception of critical patient arriving as I leave a patient's room. I will chart both at the same time though, before moving onto the next. I found by charting right away, I am there after my shift at most an hour (I like to look through all the charts and do medical decision making at the end of the shift and make sure I review all labs). I also only saw about 2-3 less patients per shift (when I was able to compare - now I see more patients). Saves time charting when the story is fresh in my head than when I have to go back to review nursing notes to see what can jog my memory.

The physicians who are most efficient in seeing patients in my ED are those who also chart on each patient as they see them.

 

[emergentmd]

I guess alot here are hour based and not RVU pay based. I am RVU, so the more I see, the more I make.

If I see 20 in 10 hrs, I get the same as if I see 20 in 5 hours.

So I like to see as many patients as possible. Most of my partners are of the same mindset.

I have learned to be super efficient. I rarely stay more than 1 hr after the next guy comes in and when I do, I get edgy. There is rarely a reason for me to stay more than 1 hr after the next guy comes in. If you are always an hr or more after the new guy comes in, you are doing something wrong.

I don't have a scribe. I have tried them and hate it. It costs me 13-15 bucks an hour and they are useless when not busy, and alittle helpful when super busy. Overall, I waste as much time reviewing their charts as I would be just doing it myself in 2 minutes.

When people ask me how I chart so quickly, do it so thoroughly, leave on time, and never write down even a single note (other than EKG findings, radiological finding), I tell them this.

Charts are done to tell a story and protect my *****. If I am discharging a chest pain that is 60 yrs old, they WILL have a chest wall pain story. If I am admitting a 40 YO chest pain, they will have an angina story. I can care less what they say half the time. I ignore 90% of their complaints. I almost never do a ROS as it is time consuming and pts will say yes to EVERYTHING. So in essence, I rarely need to know details. ALL I need to know is what their complaint was, and what their disposition is. The rest I will tell my story to fit my disposition. So yes, a 40 yr old who has pressure chest pain that I am discharging will have a sharp chest pain worse with moving his arm or touching his chest.

So I suspect all of my admission chest pain sounds the same and my discharged chest pain sounds the same. This way I can sleep well, have protection if a lawsuit comes my way (none in 12 yrs), and my charts always fits my disposition. It protects me from a medicolegal standpoint and also protects me from a billing standpoint.

 

[The White Coat Investor]

I guess alot here are hour based and not RVU pay based. I am RVU, so the more I see, the more I make.

If I see 20 in 10 hrs, I get the same as if I see 20 in 5 hours.

So I like to see as many patients as possible. Most of my partners are of the same mindset.

I have learned to be super efficient. I rarely stay more than 1 hr after the next guy comes in and when I do, I get edgy. There is rarely a reason for me to stay more than 1 hr after the next guy comes in. If you are always an hr or more after the new guy comes in, you are doing something wrong.

I don't have a scribe. I have tried them and hate it. It costs me 13-15 bucks an hour and they are useless when not busy, and alittle helpful when super busy. Overall, I waste as much time reviewing their charts as I would be just doing it myself in 2 minutes.

When people ask me how I chart so quickly, do it so thoroughly, leave on time, and never write down even a single note (other than EKG findings, radiological finding), I tell them this.

Charts are done to tell a story and protect my *****. If I am discharging a chest pain that is 60 yrs old, they WILL have a chest wall pain story. If I am admitting a 40 YO chest pain, they will have an angina story. I can care less what they say half the time. I ignore 90% of their complaints. I almost never do a ROS as it is time consuming and pts will say yes to EVERYTHING. So in essence, I rarely need to know details. ALL I need to know is what their complaint was, and what their disposition is. The rest I will tell my story to fit my disposition. So yes, a 40 yr old who has pressure chest pain that I am discharging will have a sharp chest pain worse with moving his arm or touching his chest.

So I suspect all of my admission chest pain sounds the same and my discharged chest pain sounds the same. This way I can sleep well, have protection if a lawsuit comes my way (none in 12 yrs), and my charts always fits my disposition. It protects me from a medicolegal standpoint and also protects me from a billing standpoint.

Uh.....how's it feel when you look in the mirror? Seriously, read what you just wrote. You're basically saying you're committing fraud. No wonder you make so much money. I'm not saying we don't all "buff the chart" or do a super fast review of symptoms- "You don't have headache, neck pain, visual problems, sore throat, chest pain, dyspnea, belly pain, blood in your urine, rashes, paralysis or hallucinations, right?" but most of us aren't just making crap up.

 

[emergentmd]

Come on now. I am a director at my place and review T system charts all the time. All of the T system charts look the same. other than the chief complaint, everything is checked off as negative.

If you have a level 5 pt and need 10 ROS, most docs do not ask 10 ROS. I can tell you they sure do not ask the 20 questions that is negative on their Tsystem chart.

I do look in the mirror and have no problems with what I see.

 

[Rendar5]

fevers, chills, cold or allergy symptoms, urinary problems, abd pain, n/v/d, cough, CP, SOB, rashes, weakness, headaches? Usually nets a full ROS in 15 seconds or less.

 

[deleted6669]

there's some giant unforseen danger here that i'm willfully ignorant of.

yup...delayed billing....seriously....