charting

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gman33

gman33

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Any good resources out there on charting?

As I wrap up intern year, this is something I struggle with.
Been trying to see more patients and push myself, but charting really gets in the way.

Would like to become more efficient, without leaving a chart that is full of holes.
Still takes me too long. Probably documenting a bunch of crap that doesn't need to be there and missing stuff that should be.

I'd like to come up with some sort of more systematic approach for the more common complaints.

Our EMR sucks, which is part of the issue.

On a totally unrelated topic that may derail this thread.
Any good podcasts or resource that talks about doing a neuro exam on the altered or uncooperative patient, i.e. the ones who really need a good neuro exam.
Think demented nursing home patient sent in for AMS.

Thanks.
G
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gman33 said:
Any good resources out there on charting?

As I wrap up intern year, this is something I struggle with.
Been trying to see more patients and push myself, but charting really gets in the way.

Would like to become more efficient, without leaving a chart that is full of holes.
Still takes me too long. Probably documenting a bunch of crap that doesn't need to be there and missing stuff that should be.

I'd like to come up with some sort of more systematic approach for the more common complaints.

Our EMR sucks, which is part of the issue.

On a totally unrelated topic that may derail this thread.
Any good podcasts or resource that talks about doing a neuro exam on the altered or uncooperative patient, i.e. the ones who really need a good neuro exam.
Think demented nursing home patient sent in for AMS.

Thanks.
G
Click to expand...
What helped me the most when I started my first ED job, I made a word document with common chief complaints (abd pain, chest pain, SOB, dental pain, sore throat, extremity pain, leg swelling, abscess, headache, seizure, suicidal ideations, etc), then wrote out common ddx, the "life threatening" ddx, then key history questions to ask that must be documented, key things on exam that need to be documented (I.e.- dental pain, comment "no signs of ludwigs", headache- ask about sudden onset, neck stiffness, bla bla"). sounds really basic, but after reading thru it a few times (sometimes even while i dictated the chart)i can now rattle off everything without even thinking about it when i dictate the chart. I used the EMRA chief complaint guide to get me started, then added to it with readings, and the first couple months of work I would just add in EVERYTHING i missed or had trouble remembering to mention when dictating. It used to take me a while to dictate because I had to think it through, but now I can dictate a chart in about 3-5 minutes (big improvement for me). If i come across something new or my SP mentions somthing I forgot to check or ask, I simply add it in the document. Its over 110 pages now.
 
Documenting gets better as you get better. As you learn which details matter and which don't, you'll only include the ones that matter and you'll become faster.

Remember some details matter for medical communication, some matter for billing, and some matter for medicolegal issues. They're not all the same, but they all need to be there.

For instance, doctors and lawyers don't care about the ROS, but the payers do. So when you're done asking all the stuff that matters, ask:

Anything else going on new today like headache, neck pain, visual symptoms, difficulty swallowing or hearing, chest pain, cough, abdominal pain, difficulty urinating, rashes, weakness, diabetes or hallucinations?

Then check the box "All systems reviewed and negative except as mentioned in the HPI." Don't forget the hallucinations part. It's the part that gets them to answer the question "No" so you can move on to the parts of the exam that matter.

It also helps to realize that a lot of your exam is done without really trying- vitals, general, psych, skin etc. If you also look in the mouth, listen to the heart and lungs, push on the belly and check for edema you've checked enough boxes for billing purposes.

Remember that the next doc seeing the patient only cares about a few things- the HPI, the pertinent exam points, the medical decision making (maybe) and mostly the plan. So spend some time there. Don't use check boxes for those. Type them in directly if using an EMR.

Lawyers care about your differential diagnosis, tests done, and especially the follow-up plan and instructions.
 
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ActiveDutyMD said:
Anything else going on new today like headache, neck pain, visual symptoms, difficulty swallowing or hearing, chest pain, cough, abdominal pain, difficulty urinating, rashes, weakness, diabetes or hallucinations?
Click to expand...

"Yeah, doc, I have had some trouble hearing, felt a little weak, and had some diabetes." I think that that one doesn't fit with the rest!
 
Agree. A "screening" ROS doesn't help, but will prompt the patient to come up with 10 different pseudo-complaints. Everyone has a headache in the ER....

How do you guys feel about spelling out the differential diagnosis? There was a medicolegal talk at ACEP a while ago where they explicitly recommend not to do so. With the reason being that if you include a section on the ddx, and the patient later has a problem that you didn't mention (even if it is extremely unlikely/rare, but not completely impossible), you'll be screwed. They argued that you'd be much better of explaining to the jury/lawyers "of course did I think about xyz, I always do".
 
Apollyon said:
"Yeah, doc, I have had some trouble hearing, felt a little weak, and had some diabetes." I think that that one doesn't fit with the rest!
Click to expand...

Hah. I actually laughed audibly (which is now my default when I want to communicate a literal LOL).

"Yeah, you know I think I had a couple of diabetes a few weeks back..."
 
when people start saying everything hurts, i ask them if their hair hurts... very seriously.

gets them off the train of "yes". works well w/ kiddos too.
 
EMIM2011 said:
How do you guys feel about spelling out the differential diagnosis? There was a medicolegal talk at ACEP a while ago where they explicitly recommend not to do so. With the reason being that if you include a section on the ddx, and the patient later has a problem that you didn't mention (even if it is extremely unlikely/rare, but not completely impossible), you'll be screwed. They argued that you'd be much better of explaining to the jury/lawyers "of course did I think about xyz, I always do".
Click to expand...
Why would you be screwed? That makes no sense, on any patient that is being admitted for further work-up or treatment. If you're sending them home, I can see the rationale, but it's kind of annoying to get an admit in which the documentation says nothing more than:
The patient presents with abdominal pain. The patient presents with nausea. The patient presents with vomiting. The patient presents with pain lasting greater than 1 day. The patient presents with fevers. The patient presents with chills.

Differential diagnosis: abd pain
Plan: surgery consult
Click to expand...

Our ED physicians are pretty good, but their charting system isn't worth a damn.
 
TheProwler said:
Our ED physicians are pretty good, but their charting system isn't worth a damn.
Click to expand...


Yep. I'm constantly at-odds with "management" about charting speed/efficiency. "They" point at a the computer screen and say - "Look! Its all right here! All you have to do is click the boxes that you want." They have limited idea about how it actually plays out if you're not the person doing the charting.

There was an exchange recently where another doc was criticizing me for actually typing out a narrative (paragraph or so, not the whole thing) into my HPI and not using the click-boxes like he does. I replied with... "Dude, I've read your charts on your bouncebacks... its just....random adjectives. No sentences whatsoever."
 
gutonc said:
This is brilliant. I have routinely used a very leading ROS plan in the people I know are going to be pan-positive...but this is way better.
Click to expand...

I also use the terms "no new" or "no significant" (headache, abdominal pain, etc) on the pan-positive peeps.
 
RustedFox said:
Yep. I'm constantly at-odds with "management" about charting speed/efficiency. "They" point at a the computer screen and say - "Look! Its all right here! All you have to do is click the boxes that you want." They have limited idea about how it actually plays out if you're not the person doing the charting.

There was an exchange recently where another doc was criticizing me for actually typing out a narrative (paragraph or so, not the whole thing) into my HPI and not using the click-boxes like he does. I replied with... "Dude, I've read your charts on your bouncebacks... its just....random adjectives. No sentences whatsoever."
Click to expand...

i feel your pain... i have partners who do the same BS. the chart is completely useless to the next doc. some barely even chart MDM...
 
I'm working on improving my charting as well.

One suggestion...

Read your attending charts. If you work in a system where they complete their own documentation this works great, even if its just MDM
 
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