Clinic efficiency

[ED50]

Hello, hoping to get some tips on clinic efficiency.

A little about my set up. I am a new grad and am working at a hospital. They have hired a new MA to help with rooming and I can direct them to help however I feel fit. They start in a few weeks (floats until then) I have a very brief handout that all patients fill out which includes pertinent ROS, a decent portion of HPI, and relevant procedural and medical history. I currently see patients in 30/60 min for follow up and new. Now that I am used to the EMR and clinic I can see new patients in 40 min. I feel like I will struggle to see follow ups in less then 20 min.

I currently see the patient, exam, discuss plan, then I run to my office (very close) and dictate after visit summary (required) and enter any orders. I then usually quickly finish my note and move on to the next patient. Should I not be finishing my notes between patients? If so what part of the note do you ususally finish later?

How are you using your MA's to make you more efficient? Those that are seeing patients in 15/30 how are you doing that? Any tips or things that have worked for you are appreciated.

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[lobelsteve]

Wtf.


What state are you in? You need to shadow someone.

How did they do it where you trained?

 

[deleted131481]

How did they do it where you trained?

Likely somewhere quite inefficient like 90% of academics.

Is there a computer in the room? What EMR? Finish AVS, orders in the room at minimum. I tell the patient what I'm doing and they don't mind. AVS is your plan of your note - copy/paste. The rest of note should be <5 min, sometimes I will do HPI in room as well.

Ideally MA would room efficiently and also: do all your orders, pull up MRI, review PDMP, etc. MA who is also scribe even better.

Full disclosure: I am in academics and none of the above happens here.

 

[ateria radicularis magna]

Hello, hoping to get some tips on clinic efficiency.

A little about my set up. I am a new grad and am working at a hospital. They have hired a new MA to help with rooming and I can direct them to help however I feel fit. They start in a few weeks (floats until then) I have a very brief handout that all patients fill out which includes pertinent ROS, a decent portion of HPI, and relevant procedural and medical history. I currently see patients in 30/60 min for follow up and new. Now that I am used to the EMR and clinic I can see new patients in 40 min. I feel like I will struggle to see follow ups in less then 20 min.

I currently see the patient, exam, discuss plan, then I run to my office (very close) and dictate after visit summary (required) and enter any orders. I then usually quickly finish my note and move on to the next patient. Should I not be finishing my notes between patients? If so what part of the note do you ususally finish later?

How are you using your MA's to make you more efficient? Those that are seeing patients in 15/30 how are you doing that? Any tips or things that have worked for you are appreciated.

Great questions.
1. Template stuff. You are probably doing a great job and writing actual unique notes with insightful bits. If you want to save time use templates and stick to what is necessary. You can make like 6 physical exam templates for the usual things you see and just modify them real fast.
2. As time goes on the conversations with the patients will become shorter and the exams quicker. You probably feel rude interrupting. If so, this will go away soon. I interrupt every single patient multiple times except for the guys who only give yes or no answers. These guys I ask about their families while I am testing reflexes. It took me a long time to realize that interrupting is just another skill, and is not rude at all if done the right way. This may seem wrong at first, but your time is valuable and more than one or two off topic monologues per patient is not acceptable.
3. The ma should fill in all the Med hx, ros etc and should do it very quickly. You will probably need more than one ma to make it work the way you want. You can make an “order form” for the ma or front office to work from or you can template the orders into your process.
4. Use dragon dictation or a scribe.
5. Experiment with the set up and the schedule. Make it yours. You will get a lot faster in no time.
6. Don’t let the ceos tell you what to do.
7. Figure out how to look at most of the images and show them to the patients when you can. This can be time consuming at first but is a great practice and will, like all of it, get a lot faster the more you do it.
8. One thing I used to do is really engage the patient on their medical history to make sure I understood what they had gone through previously. But now, if it’s complicated, I just stick to the few things I really need to know, and move on.
9. With regard to the physical exam, you can examine most new patients in 3 minutes. If you want to do more, more power to you, but it’s not necessary.
10. All of this will come naturally, but at times it will feel like a struggle. Just remember that struggle is a predecessor for progress.
11. Ask lots of questions of people who have been doing this stuff. When people try to make you feel dumb for asking, ignore them. They forgot where they came from.
12. Don’t have long conversations about opioids (or any medications for that matter). Don’t let the patient turn the office visit into an extended opioid argument. Be very clear with your limits. I recommend prescribing no more than 40 mme and that only if absolutely necessary. Don’t let the convo veer into the patient’s victimhood. Just express straightforward empathy, have clear limits, and move on. They can always look elsewhere.
13. Try to automate all the robotic crap you have to do with the emr, as much as possible, or it can take over your life.

Good luck!!

 

[Laryngospasm]

Optimizing exam and notes in emr is key. I do my notes Immediately after seeing patients Using templates for facet pain, radicular pain, in need of surgical referral etc. I have all my orders saved as favorites and all I have to do is click and they populate with my favorite surgeon, pt place etc.

 

[Ferrismonk]

My first job out of fellowship was 10 min OV, 20 min New pt. Hard pace but definitely doable. You need to make your MA do as much as possible. You should not do ANY intake stuff AT ALL. Spend time creating EMR templates for EVERYTHING you do more than once. Generic HPI, generic PE, most frequent orders, meaningful use crap, etc. Chart while in the room talking to the patient (just make eye contact with them and listen and they don't care, seriously).

I charted at end of day for complicated charts that needed to be bulletproof. (Potential legal action in the future, angry patient, workman's comp, auto, complicated authorization needed for something weird). Even then, make cliff-notes in your chart and just fill in the prose later.

 

[Ducttape]

chart during the appointment.

its lovely spending time with patients and making eye to eye contact, etc but impossible to keep a reasonable pace. (see Forbes article below)

templates for most of note, add in specific choice unique phrases to remind yourself and to make it unique. do this while you are talking to them. (ie "Jack Skellington facemask")

use bullet points/lists and forget the prose. saves time and in follow up you can see what you were planning much faster

scribes are great but too expensive. try dragon, or type fast. consider ignoring minor typos (truth be told, however, I cannot).

ideally, finish follow up notes before you leave the room. I leave the non-important stuff in my new patient notes for later (ROS, exam findings that are unique but not pertinent) for end of day, but make sure the important stuff is in there before leaving room, just in case you don't finish.

personally, I cant see spending less than 15 min - its the minimum amount of time I think we should be spending with patients to generate good quality interaction that the patient would appreciate. I know some orthos that spend literally 7 min. but they are just being needle jockeys.

Time To Change The 15-Minute Limit For Doctor Visits

Who said that fifteen minutes is enough time for a doctor to examine and take care of a patient? This is roughly the same amount of time men spend on the toilet each day. So, why isn't this number being questioned more?

www.forbes.com

 

[Pain Applicant1]

When I started I scheduled all new pts for one hour and f/u for 30 min and I was still doing notes at home at night. This is okay at the beginning but not sustainable for the long term.

You'll get more efficient as you become more experienced. I created a policy for myself that my notes must be done before the end of the day. Do your notes while seeing the pt. The art in it is to make the pts not realize you are doing this. They must feel that they have your undivided attention. Don't let the pts go off on tangents and bring them back quickly if you do. Again, the art in this is not letting them realize you're doing this and not coming off as rude. If they're going on and on, I'll say something along the lines of "I definitely want to hear the rest of the story but I can't fall too far behind because I don't want to make the next pt wait" etc. Focus your physical exam on only those things which will affect the course of treatment. You will get much faster.

I now schedule new pts for 30 min and f/u for 10 and my notes are typically done and signed off on before the end of the appt.. I could literally wrap both appts up in 5 min but the pt's must feel that they get their money's worth.

 

[DOctorJay]

having 2 MAs (I only get one) and having them input orders (mine can't/won't) would definitely improve my efficiency. I'm 15 min follow ups and 30 min consults.

I find that if I place orders or do any of the note in the exam room it just opens the patient up to asking me another question and another question so I just get out and get the orders done, finalize the note, and move on.

may get to try out a virtual scribe this year, we'll see what the network does.

 

[lobelsteve]

10min fu, 20min new.
I look at images and outside notes.
I do not touch the computer.
I do not enter orders.

Staff's job to do everything but ask the follow-up questions from completed forms and do exam.
I write on billing sheet what they need to do while talking to the patient.
Dictate after each encounter (1-2 min).
3 staff clinically.
Check in, check out, billing, precert done by other staff.

 

[Baron Samedi]

"Let's focus on the future and not on the past" when patients start talking about their car accident in 1992 or doctors they didn't like in the past.

 

[ED50]

Great advice and tips. Thanks! When I graduated fellowship my focus has been on good medicine - quality and consistency. Being out for a few months I feel like I have my feet on the ground and can start to move towards efficiency. I have smart phrases but not as detailed as many here. I will work on that. The more time I spend in the room the more questions I get asked so I'll try to be a little better at that too.

 

[ED50]

Reviving this thread, wondering if someone could share their order/billing sheet they have their staff work off of. Thanks for all the great tips previously, I have implemented many of them.