Difficulty getting charting completed in a timely manner

[MeganRose]

I have been working as an attending in FM at a military clinic since graduating from residency in July. I don't know if my lifestyle expectations were unreasonable but I feel as if I'm drowning in charts and not living the hours that I had anticipated. Each day, I see 23-25pt with 1-3 procedures. My day starts at 0630/0700 with the first patient scheduled at 0730. I typically work through lunch and finish around 4:30. This sounds so much earlier when I say it but I usually have at least 10charts from the day to finish. I go home, do family things then usually chart, check labs and do phone calls from 7p to 10p+ and still, I am behind. I know some of the problem is the crappy EMR but I enjoy life and I'm looking for a way to make this work. Does anyone have any suggestions on how to make this work in real life?

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[deleted87716]

I think the key is not letting things pile up.

Try to get your notes done while you're with the patients. That will definitely help. Also, try to stay on top of labs, phone calls, etc. during the course of the day instead of saving them until the end. Do them a few at a time in between seeing patients. Give patients refills of their chronic meds during appointments. Don't encourage refills in between office visits. That just creates needless extra work. Delegate as much "scut" as you reasonably can to staff (forms, etc.).

If you're having trouble managing your time in the exam room, that's a whole different issue. However, staying on-schedule as much as possible will help avoid that "overwhelmed" feeling. This just takes practice. What you don't want to do at this stage is develop a lot of bad habits.

 

[JustPlainBill]

I think the key is not letting things pile up.

Try to get your notes done while you're with the patients. That will definitely help. Also, try to stay on top of labs, phone calls, etc. during the course of the day instead of saving them until the end. Do them a few at a time in between seeing patients. Give patients refills of their chronic meds during appointments. Don't encourage refills in between office visits. That just creates needless extra work. Delegate as much "scut" as you reasonably can to staff (forms, etc.).

If you're having trouble managing your time in the exam room, that's a whole different issue. However, staying on-schedule as much as possible will help avoid that "overwhelmed" feeling. This just takes practice. What you don't want to do at this stage is develop a lot of bad habits.

I do have a question about that --- just started an FM residency this year and continuously running behind....would you mind sharing some tips to be more efficient? We regularly deal with complex, county hospital patients who more often than not have languge barriers and are still having to have the attending go in after us in the exam room.

I'm working to get comfortable doing the physical exam/interview at the same time without losing track of what I'm checking and why -- I tend to be pedantic and do it by the numbers - interview, PE, note, present....

Anything else I can do? Also, is it rude to work on your note in the room (EMR) while conducting the interview....the rooms weren't built with computers in mind so you wind up with your back to the patient more often than not....

right now, 6 in 4 hours is a stretch and 8 is a madhouse.....

 

[deleted87716]

Don't worry too much about time as a first-year resident, especially with the typical residency-type patients you described. Focus on learning. At this point, doing things "by the numbers" is probably best. You can work on efficiency as you go along. It gets easier as you become more comfortable with your diagnosis and management. One efficiency trick is to get some of your history while you examine the patient. Another is the "pre-visit," which is basically a review of the chart, any labs/studies since the last visit, and the formulation of a "game plan" prior to walking into the exam room. This only takes a minute. After greeting the patient, the first thing I ask is whether or not they have any issues that they want to address during the visit. This helps me budget our time between what I want to cover and what they want taken care of, and helps avoid the ol' "by the way, doc" when you have your hand on the doorknob. A patient with numerous new complaints will select the most important 1-2 to address during today's visit, and will be asked to make another appointment for the others.

Charting as you go is definitely helpful, but I would advise against turning your back on patients to type into the EMR. If the room isn't designed properly, consider using a tablet PC on your lap or a mobile cart, if possible.

 

[JustPlainBill]

Don't worry too much about time as a first-year resident, especially with the typical residency-type patients you described. Focus on learning. At this point, doing things "by the numbers" is probably best. You can work on efficiency as you go along. It gets easier as you become more comfortable with your diagnosis and management. One efficiency trick is to get some of your history while you examine the patient. Another is the "pre-visit," which is basically a review of the chart, any labs/studies since the last visit, and the formulation of a "game plan" prior to walking into the exam room. This only takes a minute. After greeting the patient, the first thing I ask is whether or not they have any issues that they want to address during the visit. This helps me budget our time between what I want to cover and what they want taken care of, and helps avoid the ol' "by the way, doc" when you have your hand on the doorknob. A patient with numerous new complaints will select the most important 1-2 to address during today's visit, and will be asked to make another appointment for the others.

Charting as you go is definitely helpful, but I would advise against turning your back on patients to type into the EMR. If the room isn't designed properly, consider using a tablet PC on your lap or a mobile cart, if possible.

Thanks, BD - I like the 'anything you want to address' question.....They're trying to train us to ask for all the issues by literally using 'anything else' type of questioning until the patient runs out of problems and then prioritize those problems and reschedule the others. Nice thought in theory, but I spent 20 minutes doing that with a patient and asked my attending how to better manage it. They said they'd show me and we went back into the room. 25 minutes later, they walked out shaking their head.....Your way of questioning will help identify and focus that from the get go.....

Also - for my own peace of mind - what level of training is an intern expected to be at? I have been told that intern year is where you learn treatments and management but it's coming across as though I should know things as if I'm an attending already. For example, had never calculated fluid repletion before...was never expected to in school. When asked about a deficit and how much needed to be repleted, I simply answered, "I don't know at this time". That was seen as a negative and a deficiency in my abilities. I'm thinking,"What the heck is residency for if I'm supposed to know everything already?"....

 

[deleted87716]

You aren't expected to know everything, but you need to become familiar with how to find the answers. Saying, "I don't know" is fine, as long as it's followed by "but I'll find out." 😉

 

[MeganRose]

I think the key is not letting things pile up.

Try to get your notes done while you're with the patients. That will definitely help. Also, try to stay on top of labs, phone calls, etc. during the course of the day instead of saving them until the end. Do them a few at a time in between seeing patients. Give patients refills of their chronic meds during appointments. Don't encourage refills in between office visits. That just creates needless extra work. Delegate as much "scut" as you reasonably can to staff (forms, etc.).

If you're having trouble managing your time in the exam room, that's a whole different issue. However, staying on-schedule as much as possible will help avoid that "overwhelmed" feeling. This just takes practice. What you don't want to do at this stage is develop a lot of bad habits.

I typically stay on time or 15-30minutes behind during the day. Thanks for the advice, I generally don't do labs and calls during the day, I'll give this a try.

 

[MLT2MT2DO]

I typically stay on time or 15-30minutes behind during the day. Thanks for the advice, I generally don't do labs and calls during the day, I'll give this a try.

Not sure if it is an Air Force hospital but if it is. This seems to be the norm for our new providers, and even many of our season providers end up staying until 7pm one or two nights a week.

 

[JustPlainBill]

You aren't expected to know everything, but you need to become familiar with how to find the answers. Saying, "I don't know" is fine, as long as it's followed by "but I'll find out." 😉

Ok, so here's a question along those lines -- we're supposed to be evaluated in December to see if we still need to present our patients and have the attending see them after we do -- in effect, can we 'solo' or not? How does it look/what does it impact for those who aren't allowed to 'solo'? I've been told repeatedly that intern year is where you really learn treatments but the way it comes across, it's like you're already supposed to know them cold w/o needing to look them up.

 

[smq123]

Ok, so here's a question along those lines -- we're supposed to be evaluated in December to see if we still need to present our patients and have the attending see them after we do -- in effect, can we 'solo' or not? How does it look/what does it impact for those who aren't allowed to 'solo'? I've been told repeatedly that intern year is where you really learn treatments but the way it comes across, it's like you're already supposed to know them cold w/o needing to look them up.

Going "solo" doesn't mean knowing every single treatment for every single condition without looking them up.

What they're concerned about for the second half of intern year is whether or not they can trust your clinical judgement. Can you correctly assess wheezing in a child? How accurate are your abdominal exams? Can you tell when a patient is really sick and should be sent to the ER now, or are you oblivious to how unstable they really are? Can you correctly do a pap smear or do you still have a lot of trouble finding the cervix in most of your patients? Etc.

They also want to make sure that your plans are on target. Are you giving people with UTIs the appropriate abx, or are you giving them something weird like clinda or flagyl? Do you know when MRSA coverage is warranted or not?

Even attendings have to look things up. That's not what your attendings are really concerned about, at this point.

 

[JustPlainBill]

Going "solo" doesn't mean knowing every single treatment for every single condition without looking them up.

What they're concerned about for the second half of intern year is whether or not they can trust your clinical judgement. Can you correctly assess wheezing in a child? How accurate are your abdominal exams? Can you tell when a patient is really sick and should be sent to the ER now, or are you oblivious to how unstable they really are? Can you correctly do a pap smear or do you still have a lot of trouble finding the cervix in most of your patients? Etc.

They also want to make sure that your plans are on target. Are you giving people with UTIs the appropriate abx, or are you giving them something weird like clinda or flagyl? Do you know when MRSA coverage is warranted or not?

Even attendings have to look things up. That's not what your attendings are really concerned about, at this point.

So essentially if someone is not 'cut loose' at 6 months, the attendings don't trust their clinical judgement. I suppose theoretcally that if improvement isn't shown, a person could wind up not being promoted to PGY2 and thus be in jeopardy of being booted from the residency given that ACGME only gives you 3 years to complete an FM residency and then the program has to eat your salary for every year over 3 it takes you to complete it, correct?

How regularly does someone get 'held back'?