Do you leave on time?

[Backpack234]

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Do you ever leave on time? If you do, are all your charts done? And more importantly, what steps does your shop take to make sure you leave on time? Looking for ideas on how to get better.

 

[southerndoc]

50/50. We can sign things out, but I usually don't. I used to get out on time 95% of the time when we were adequately staffed. Today sucks. I've been waiting 2.5 hours for a CT because we don't have enough CT techs. Covid has changed our staffing environment like all other facilities. It's made it much worse getting out on time.

 

[Rekt]

Going to depend on set up. RVU based are significantly less likely to sign out and you'll be staying. When I moonlight I spend 1 minute singning out then leave since it's hourly.

I've spent PGY3 perfecting this. I pretty much always leave on time or even early with all charts done and still easily can see 2.5-3pph without midlevels or scribes.

All it does is take focus. It literally takes less than 5 minutes to finish a chart. Realistically you should be done in 1-2 minutes. The easiest way to stay caught up is do nothing else except finish your chart after you dispo a pt. There's really no excuse. Even when I get a code/trauma/stroke alert I still finish the chart after orders. Nothing is worse for your well being than charting from home or staying late for no reason.

 

[emergentmd]

Do you ever leave on time? If you do, are all your charts done? And more importantly, what steps does your shop take to make sure you leave on time? Looking for ideas on how to get better.

In the 17 years in the pit, I would say I leave within 30 min 95% of the time and majority when my relief comes in. Once did I leave 2 hrs after my shift and that was in the 1st month of being an attending and I did everything in my power to leave on time.

This topic has been discussed in many forms before and I have a list of what you need to do to leave on time. Just do a search.

Bottom line is, you are not paid to stay back in most shops and I will do everything in my power to not work for free.

 

[Tenk]

Usually I leave on time or like +/-15. On the nights like tonight when I meet my favorite charge nurse at In N Out after midnight you better believe I’m leaving on time.

 

[BoardingDoc]

Do you ever leave on time? If you do, are all your charts done? And more importantly, what steps does your shop take to make sure you leave on time? Looking for ideas on how to get better.

This is entirely shop and setup dependent. If you are straight hourly, there should be a system in place where you always leave on time, barring you being solely responsible for an actively crashing patient.

I work in a shop which is purely productivity based. I stay until things are generally tidy with minimal signout involved. Some of us are better at that than others. I generally leave within 30 min of the end of my shift.

 

[miacomet]

No, but we get paid for every minute we are there.

 

[Groove]

I almost always leave on time. 100% charts complete. The discipline is to take care of yourself and resist the urge to pick up patients during your last 1-1.5 hours. Depending on the shop, if flow is terrible...that might even be 2+ hours, it all depends. The problem is that patients start to sit on the board and you feel pressured to pick them up mentally castigating yourself for "being weak" or "not being a team player", imagining judgmental thoughts from your colleagues, etc.. You've just got to get over this and start taking care of yourself. Most CMGs are not paying you stay over extra or even to document for 2 hours at home after your shift. Habitual long shifts where you are routinely staying late with only 20% of your charts done is a recipe for burnout.

Now, in the interests of flow, what I will do during that 1.5 hours (besides finishing my notes) is walk around and eyeball the new patients and dump in MSE orders to help out the oncoming docs. About 1 out of every 5 will be something that was listed as an ESI 3 but is more like an ESI 4-5 and you can quickly pick them up / dispo. (Or a transferred pt that already has everything done and needs a simple admission, etc..) I will also identify on the tracking board any quick treat&street complaints and also decompress in that way. But no way am I going to pick up an elderly belly pain, dizzy, messy lac repair or nursing home patient as I'm trying to wind down. That's just setting yourself up for staying 2-3 hours after your shift or an annoying sign out where you are turning over 3-4 complicated patients to your colleague who is inwardly rolling their eyes. With that above system, I almost never have to sign out patients unless they are psych, etc.. Of the patients that I've screened that are of concern, I'll give them a heads up and say that Room X,Y,Z needs to be seen first and I've started the work up for them, etc..

I've got a colleague who is always 1-2 hours late and spends an entire day off catching up on a week's worth of charts. No thanks.

 

[Angry Birds]

I work 12 hour night shifts so yes.

 

[emergentmd]

Do these 2 and you will always leave close to schedule.

#1. Be EMR efficient. You should not take more than 3-5 min/chart. I do a chart in about 1-2 min. Yes I have timed myself. I have done 30 charts in an hr.

#2. Start to close up shop in 2 hrs before shirt ends . Do not do anything that will take more than 90 min. If u pick up a complicated belly pain or neuro case 60 min before checkout then that is your fault and have no one else to blame when ur stuck 2 hrs after shift

 

[RustedFox]

Do these 2 and you will always leave close to schedule.

#1. Be EMR efficient. You should not take more than 3-5 min/chart. I do a chart in about 1-2 min. Yes I have timed myself. I have done 30 charts in an hr.

#2. Start to close up shop in 2 hrs before shirt ends . Do not do anything that will take more than 90 min. If u pick up a complicated belly pain or neuro case 60 min before checkout then that is your fault and have no one else to blame when ur stuck 2 hrs after shift

That's cool if you have overlapping coverage, bro.

 

[emergentmd]

Just more excuses to work for free.

I have worked at single coverage busy shops, it can be done. if a complicated pt comes in 60 min before shift, then order a bunch of stuff and pass it on. Everyone is on board with getting docs off on time.

I hear excuses all the time and 99% of the time, its the doc fault for not getting home on time. Some docs want to pick up every last morel of RVU then complain that they can't get out on time.

 

[cyanide12345678]

Usually 30 minutes over at my busy shop, mostly tying things up. Notes are done by scribes.

70-80 percent on time at my rural shops during day shift, 100% on time at night shift. Sometimes i might have a couple of notes if the last 2-3 hours got busy, since it’s single coverage. Sometimes i just get really lazy about finishing notes at work by choice. I find it much more enjoyable to do notes while watching Netflix and laying on a couch.

I usually have 21 days to finish notes.

 

[Mount Asclepius]

“On time” is somewhat of a misnomer depending upon the setup. I get out when the work is done. Slow shift, then leave early or when it’s scheduled to end. Busy shift, then stay late cleaning up. In a setup where you eat what you kill, I’d rather stay a while after my shift is scheduled to end. Leaving “on time” doesn’t mean you’re better, it can also mean less income. Efficiency per the amount of work present is more important. If you write all charts in 1-2 minutes, many of them are poor quality, or you are only seeing urgent care acuity patients. We all know docs who skimp on charting, and they often skimp on quality of care too.

 

[HemorrhagicShock]

If you write all charts in 1-2 minutes, many of them are poor quality, or you are only seeing urgent care acuity patients. We all know docs who skimp on charting, and they often skimp on quality of care too.

This has always been my thought when I hear the oft-mentioned "if you spend more than 1-2 minutes dictating out a chart you're wasting your time" which I read fairly frequently around here.

I still don't get how you chart a billable, defensible, and medically usable chart on a 45-year-old female non-compliant extremely-poor-historian ESRD, DM2, HTN, Lupus patient who presents with dizziness within 2 minutes. I've had some of you explain your process and I've tried to implement smart templating with dragon dictation as suggested but I just can't get a patient like that down to two minutes of charting time.

Relying on scribes to do any part of my note ends up creating MORE work in my experience (our scribes are generally low-quality and don't spend the time/effort to learn each physician's practice.... though I don't blame them, they get paid minimum wage for what amounts to an awful job with a terrible circadian rhythm)

A patient like that will take me at least 5 minutes with Cerner FirstNet and Dragon. Help!

 

[RustedFox]

This has always been my thought when I hear the oft-mentioned "if you spend more than 1-2 minutes dictating out a chart you're wasting your time" which I read fairly frequently around here.

I still don't get how you chart a billable, defensible, and medically usable chart on a 45-year-old female non-compliant extremely-poor-historian ESRD, DM2, HTN, Lupus patient who presents with dizziness within 2 minutes. I've had some of you explain your process and I've tried to implement smart templating with dragon dictation as suggested but I just can't get a patient like that down to two minutes of charting time.

Relying on scribes to do any part of my note ends up creating MORE work in my experience (our scribes are generally low-quality and don't spend the time/effort to learn each physician's practice.... though I don't blame them, they get paid minimum wage for what amounts to an awful job with a terrible circadian rhythm)

A patient like that will take me at least 5 minutes with Cerner FirstNet and Dragon. Help!

A few years ago on here, I ranted about the low quality of scribes in general, and the students all MF'ed me on here.

I wonder how they feel now.

 

[southerndoc]

This has always been my thought when I hear the oft-mentioned "if you spend more than 1-2 minutes dictating out a chart you're wasting your time" which I read fairly frequently around here.

I still don't get how you chart a billable, defensible, and medically usable chart on a 45-year-old female non-compliant extremely-poor-historian ESRD, DM2, HTN, Lupus patient who presents with dizziness within 2 minutes. I've had some of you explain your process and I've tried to implement smart templating with dragon dictation as suggested but I just can't get a patient like that down to two minutes of charting time.

Relying on scribes to do any part of my note ends up creating MORE work in my experience (our scribes are generally low-quality and don't spend the time/effort to learn each physician's practice.... though I don't blame them, they get paid minimum wage for what amounts to an awful job with a terrible circadian rhythm)

A patient like that will take me at least 5 minutes with Cerner FirstNet and Dragon. Help!

I bring up the Dragon dictation box, start dictating my history, and simultaneously click my review of systems and physical exam macros. I have several for each. Even so specific to specify left flank pain and right flank pain, RLQ abdominal tenderness that makes everything else normal, dehydration, dehydration with tachycardia, asthma, asthma distress, CHF, CHF distress, etc. You'd be surprised at the number of macros I have.

While I'm dictating, I'll also change the ROS and physical exam templates to alter things that are different from the macro or to deselect stuff I didn't check. Also while dictating I'll go through the triage tab and sometimes past notes quickly -- I'm a speed reader.

Transfer the next, his my macro button to advance to next field (Epic field is marked by {***} meaning it's a hard stop). I have my left rewind button on my SpeechMike microphone programmed to basically act as an F2 button. I'm holding the microphone in my left hand dictating with it and moving fields while using my mouse to change anything in the template or to navigate different areas of EMR (like triage tab, discharge summary, etc.).

After transferring the test, I go to the MDM next and will bring up a macro for what I think is going on. "Macro differential appendicitis, macro differential early pregnancy, macro differential Covid," etc. Some have {***} with things such as {Check urine pregnancy test} in the Dragon macro itself. I can click the forward button and it'll select it. I can then delete if necessary (like the pregnancy test in a male patient) by simply saying "delete that." If I hit "F2" on my microphone, it removes all the {} and makes them as default. For example, if it's a female patient that needs a pregnancy test, it'll remove the "{}" and make "check pregnancy test" the default. I transfer that.

Below that is another {***} that is where I summarize things. "Macro now" will bring up the current time and place a colon after it. I then open the dictation box and start dictating what I found, what was ruled out, and disposition of patient. I have macros for admitting to the hospitalist, admitting to cardiology, etc. that will bring up diagnosis, treatment given in the ER (pulled from orders), etc. "Macro discharge" will do the same thing plus pull up discharge medications, follow-up appointments, etc. All notes end with this.

I periodically use the ED course in the Epic workup tab to automatically time things. Examples: "Discussed with Dr. XYZ, hospitalist who will admit patient. The admitting team will follow up on all pending results." (I can tell you about that when my litigation is over.) I will click abnormal values and write what the prior was (like a creatinine and then comment it was normal 2 months ago, etc.). This especially helps justify any patient with critical care because it shows continuous involvement if a chart was reviewed.

I can do a normal routine note in <2 minutes with this. More complicated cases where I really go through the MDM/workup may take up to 5 minutes.

Resident attestations take more time because I have to dictate a brief history, pertinent physical findings, and then summarize the ED course. Since doing this, more of my charts support a level 5. Resident attestations also pull in diagnosis, ED workup, but doesn't mention disposition (I dictate that).

 

[thegenius]

I'm usually 1 hr late, seeing around 2.5 to 3/hr. It doesn't bother me too much. Signing out patients loses RVUs where I work

 

[emergentmd]

I have used probably the most difficult EMR (DOS based meditech) known to man. You still can do MACROS and I had macros for 95% of the most common diagnosis. Its just minor changes, and a bunch of copy/paste.

I will never understand why docs still think charts are to be created to tell the pts story. It is used to bill, and to tell the story that the writer wants. If a pt goes home, this writer will make it as plain as possible. If they are admitted, this writer will write a story that confirms need for admission.

Any doc that can not do a chart in an avg of 3 minutes needs to figure out how to do it. If you are stuck on telling the pt's complete story, then you just have to accept that you will be working for free charting.

I will tell you that your chart is rarely ever read by another Er doc or admitting doc.

This thread was started by OP who wanted to know if docs leave on time and how they achieve it.

You will not leave on time if
1. You spend 5+ minutes on each chart
2. If you chase every possible RVU
3. If you pick up complicated pts the last hr.

I quickly figured out #1&3 in my career. For #2, figure out how to be efficient, pick up lots of charts early, the RVUs will come. In my attending career, I was almost always #1 in RVUs/pph while still leaving on time.

I learned to type really fast. Some attendings still typed with two fingers and its their fault for not taking at typing class. Correct your inefficiencies.

 

[thegenius]

I like how you have "Commandments". Absolute Truisms. The Truisms of "Emergentmd"

I read my colleagues charts all the time. They read mine. The admitting docs read my charts all the time. They say things like "You wrote that...."

 

[Apollyon]

I have used probably the most difficult EMR (DOS based meditech) known to man.

Not to bust your "Iron Man" post, but, it looks like you've never seen Healthland. No macros, ABSOLUTE s*it, and strongly contributed to my burnout. Even you, playa, might not have been so expeditious, were you to use such a POS EMR.

 

[dadaddadaBATMAN]

I generally leave somewhere between 20 minutes early and 20 minutes late. I see about 2-2.5 hr, but my site is really inefficient so that puts me at the high end (labs take 90min-two hours, frequent redraws, start my own iv 10% of time due to inability to stick by rn, ct might take 2-3hrs).

I work at a medium size community site with good overlap. I rarely pick up patients in the last hour more complicated than an ankle sprain unless multiple codes or peri code patients arrive. My partners don’t care because when I take over for them I stop them seeing patients the last two-2.5 hrs by taking everything the second it’s on the board.

Charting: I agree with @Rekt. Charting has to be done as you go.

I think this is important both for leaving on time and for patient care. Charting is my quality control, it’s where I realize I can’t justify not getting a dimer or that I forgot to order a plain film of the xyz.

I chart hpi, ros, exam in about 30s-90s. The worse a historian the patient is the quicker this is. I include one or two ludicrous examples of their attempts at answers and then make a brief but kind statement in the mdm about the limited history.

I spend 1.5-3 minutes on my mdm, depending on complexity of decision making. I follow a formula of age, comorbidities (to remind myself, I know this drives some people crazy), a differential (this is where I realize what I forgot to ask or order), and then what testing I’m doing. I give a brief statement on why I think xyz is likely or unlikely. Before I finish a chart/dispo, which I do together most of the time, I make sure every lab or image gets a brief second look and an interpretation if it’s pertinent, which cuts down on overlooking that new creatinine of 12 or unexpected sodium of 118.

Total time between 3-5 minutes for charts that bill well in my experience.

I find that when I don’t do this, my patterns mirror my less efficient partners where I’m suddenly ordering a new ct 2 hrs in or adding on 2 pertinent labs, or realizing the nursing note mentioned melanotic stool the family of mi-maw denied 10 minutes later.

Charting as you go makes you create time for dedicated thought for each patient. It’s good care, not just selfish. It’s easy to see 10 new people on the board in 10 minutes and decide to put off charting indefinitely, but it’s not disciplined, it will make you suffer, and you will actually be slower.

Good ability to chart as you go= organized, systemic approach. Organized chart = organized mind.

However, this doesn’t excuse the people who spend like 15 minutes writing a tale of two patients before picking up the next patient and seeing 1/hr. We all know a doc or pa that does this and they suck (the notes are usually unreadable too).

 

[Groove]

I don't think single coverage changes anything for me.

One of my sites is single coverage and I just screen people the last 1.5-2 hours. I'll go see them, drop in orders. If I anticipated wrong and it's done before the next doc walks in, I'll just dispo them myself. I don't even write notes on these people. I let the incoming doc pick them up and start the note. I briefly will tell them "Hey, I screened all your patients to be seen and started orders...8 is a r/o appy, 9 is SI that needs psych eval and has a sitter, 7 is a TIA, old guy..lots of risk factors, I'd put him in even though he's asymptomatic when everything is back, 11 is an ACS rule out, etc..

If it's a dental pain or simple MSK case or something I'll pick that one up and do the note. I personally don't ever think someone should be signing out 5-7 patients to an incoming doc. If I was the doc, I'd much rather have a fresh note that I completed myself without someone else mentioning a variety of differentials that I might not think needs mentioning. I also can't delete certain key entries in Epic, so if you say "May consider LP if work up does not reveal a metabolic origin for his neuro symptoms..." I'm stuck with that in my note and I can't delete it. Just put in MSE orders (so helpful to incoming docs) and let me get my own history, do my own note and put everything in my own words. I'm one of those docs that NEVER minds having several patients to pick up when I get to work. That's when I'm fresh and that's just to be expected at the beginning of a shift. I don't need you doing gymnastics to "clear the board" and prove to me that you've been working the whole time. I KNOW you've been working. I also KNOW the randomness of pt boluses when 20 people check in the last hour. I'm not going to judge you, trust me. The MSE orders are gold. Just get your stuff finished and get out on time because that's what I would do for myself.

 

[Groove]

A few years ago on here, I ranted about the low quality of scribes in general, and the students all MF'ed me on here.

I wonder how they feel now.

I still don't use them and am definitely faster now. My notes aren't as fleshed out as they are with a scribe but I also know exactly what is in the note and don't have to worry if the scribe is documenting things that I don't want documented. I haven't really noticed a slow down in my PPH. I'm still upper 50% where I work. I usually have the best LOS and TATs but I don't think that has anything to do with scribes.

 

[BoardingDoc]

I have used probably the most difficult EMR (DOS based meditech) known to man. You still can do MACROS and I had macros for 95% of the most common diagnosis. Its just minor changes, and a bunch of copy/paste.

I will never understand why docs still think charts are to be created to tell the pts story. It is used to bill, and to tell the story that the writer wants. If a pt goes home, this writer will make it as plain as possible. If they are admitted, this writer will write a story that confirms need for admission.

Any doc that can not do a chart in an avg of 3 minutes needs to figure out how to do it. If you are stuck on telling the pt's complete story, then you just have to accept that you will be working for free charting.

I will tell you that your chart is rarely ever read by another Er doc or admitting doc.

This thread was started by OP who wanted to know if docs leave on time and how they achieve it.

You will not leave on time if
1. You spend 5+ minutes on each chart
2. If you chase every possible RVU
3. If you pick up complicated pts the last hr.

I quickly figured out #1&3 in my career. For #2, figure out how to be efficient, pick up lots of charts early, the RVUs will come. In my attending career, I was almost always #1 in RVUs/pph while still leaving on time.

I learned to type really fast. Some attendings still typed with two fingers and its their fault for not taking at typing class. Correct your inefficiencies.

I understand your sentiment and agree with a bunch of it, but some of this stuff is only applicable to your own experience and not generalizable.

I also used DOS meditech. I happened to like it quite a bit as it was fast as hell because it didn't spend ages loading up tons of fancy images and other crap that I didn't need to see.

The inpatient team reads every single chart I write on an admitted patient. This is because I don't ever talk to the hospitalists in my shop (except in rare occasions to clarify something). We have e-signout where I click a button, hospitalist gets a page, they read my chart and click accepted. A detailed chart is far more likely to be accepted than the one liner which begs them to click the "discussion requested" button instead.

I generally agree with your 3 bullet points.
1: Not all charts need to be detailed. Some do.
2: Chasing RVUs is great until it leads to leaving late. I agree.
3: Agree. If they're not actively dying, they get their workup started and orders placed. I will physically go see them if they look remotely sick, but I'm not signing up for them unless they're literally trying to die.

Typing fast is good. I type very fast. Dragon is better.

 

[Dr Mantis Toboggan]

I still don't use them and am definitely faster now. My notes aren't as fleshed out as they are with a scribe but I also know exactly what is in the note and don't have to worry if the scribe is documenting things that I don't want documented. I haven't really noticed a slow down in my PPH. I'm still upper 50% where I work. I usually have the best LOS and TATs but I don't think that has anything to do with scribes.

All depends on the scribe. This is what a few of ours have recently gone on to do just after working with us:

1) dental school grad current oral surgery resident

2) med school about to start opthy

3) med school current EM resident (sucker) at very competitive residency out west

4) PA student

Etc.

The smart ones are great and we did legitimately help some of these folks achieve their career goals.

 

[emergentmd]

Not to bust your "Iron Man" post, but, it looks like you've never seen Healthland. No macros, ABSOLUTE s*it, and strongly contributed to my burnout. Even you, playa, might not have been so expeditious, were you to use such a POS EMR.

I will bet you that DOS Based meditech would be worse or equally bad compared to Healthland. Dos Based (there was not even a mouse, just words and pages you scroll through with directional arrows). I figured out to do Macros on google calendar (that was one of the few websites back in the day that allowed long notes bc they didn't even have word installed), and did my note on google calendar then pasted the whole sections at a time. Never had a complaint from the hospital or biller that my notes where lacking.

I was the director and I had about the only chart that made any medical sense. The rests looked like a bunch of babble a 6 yr old would say.

I have used EPIC, paper T, Dos based meditech, Post Dos based meditech, Computer Tsystem, computer Epower. Every EMR has heir own issues, but they all can be gamed.