Documentation: How can I be more efficient?

[SpongeBob DoctorPants]

I'll be honest, I hate documentation, yet I feel that I do too much of it.

Certainly, I need to document enough information for billing purposes, and from a risk management perspective I try to include enough information in my note to protect myself should I ever get sued. In my evaluations I include enough detail to support making a diagnosis, but I probably also include a lot of unnecessary detail. My goal is to document as little as possible yet have these bases covered. I also don't like typing much during the clinical encounter, as I feel it interferes somewhat with the interview.

I have seen the notes of other providers vary from brief to lengthy. A general trend I observed in residency was that medical students wrote extremely long notes, residents wrote somewhat long notes, and attendings wrote very short notes. With experience comes the ability to be more concise.

At one extreme, however, one of my attendings in residency never appeared to type anything in her notes; it was all done by "point-and-click" in the EMR. Perhaps with the exception of new patient evaluations, she would never type any free text in the subjective section, and she wouldn't type anything in her plan, either, since the EMR automatically inserted the medications prescribed. Her notes were about as simple as any note could possibly be, but I don't know if that ever resulted in any problems with getting paid, etc. I don't necessarily want to document that little, though it would be nice; I think having at least some detail would be helpful so I can remind myself (or inform others) of what is going on with the patient.

Does anyone have suggestions for efficient note writing?

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[Shufflin]

Somewhat setting dependent. If private practice, write notes by hand while patient talks keeping most of your eye contact on patient. When the encounter is done, so are you. If inpatient, the EMR should have a template that fills in a lot of it and you just click and then type something in 2 minutes time. Both efficient.

 

[Fan_of_Meehl]

Somewhat setting dependent. If private practice, write notes by hand while patient talks keeping most of your eye contact on patient. When the encounter is done, so are you. If inpatient, the EMR should have a template that fills in a lot of it and you just click and then type something in 2 minutes time. Both efficient.

I also think that writing is an excellent way to clarify your thinking and clinical case formulation (and to, conveniently, create a permanent record of same), which tends to come in handy when you're trying to make incremental progress on a clinical case over time. But, unfortunately, current models of mental health care/practice often do not reward high quality clinical work.

 

[justfolks]

Somewhat setting dependent. If private practice, write notes by hand while patient talks keeping most of your eye contact on patient. When the encounter is done, so are you. If inpatient, the EMR should have a template that fills in a lot of it and you just click and then type something in 2 minutes time. Both efficient.

Just a patient, but strongly recommend against this for private practice therapy patients. I saw someone very briefly who spent the whole time taking notes, it was extremely distracting to her and to me. Current psychiatrist took notes during the first couple of sessions and never since. His sessions are 45 mins. each, back to back, and I think he does brief notes in between, so my session might be a minute or three shorter than otherwise but I know I have his full attention while I'm there, which is much better, especially when discussing really tough things.

 

[pizzicarella]

Just a patient, but strongly recommend against this for private practice therapy patients. I saw someone very briefly who spent the whole time taking notes, it was extremely distracting to her and to me. Current psychiatrist took notes during the first couple of sessions and never since. His sessions are 45 mins. each, back to back, and I think he does brief notes in between, so my session might be a minute or three shorter than otherwise but I know I have his full attention while I'm there, which is much better, especially when discussing really tough things.

Personally, I don't mind my treating practitioner taking notes during a session - I think how comfortable this feels for the patient has more to do with the skill of the practitioner than with the note taking itself. My psychiatrist, for example, takes notes during every session and I barely notice that he's writing them. In contrast, when I was being seen in the community mental health team my case manager would have to do a lengthy MSE every appointment which detracted from the therapy.

Professionally (perinatal mental health nurse here, working in a mother-baby inpatient unit), my notes for individual therapy can range from three or four sentences that amount to "attended DBT session, homework completed, nil safety concerns" to very lengthy MSEs and risk assessments. I don't tend to write much during sessions, unless there is an important piece of information, or something said that would be used as evidence of risk etc. When I am working on the wards documentation is much more important and follows a very standard format on the observed behaviour, thought processes and mood of the patient, as well as parent-infant interaction (and any risks there), something written about response to meds or ECT and any side effects, plus results from MMSE or MoCA etc. for ECT patients. Our consultants and registrars tend to meet with patients only with a nurse (or another registrar) also present, and usually this person will write the full content of the conversation while the primary conducts their assessments. Consultant's plans in case notes are very brief, usually because there are extensive notes and formal assessments written by the nurses. Risk assessments tend to be lengthy, more so than in general adult inpatient units because we have the safety of the infant to think about too.

 

[Shufflin]

Just a patient, but strongly recommend against this for private practice therapy patients. I saw someone very briefly who spent the whole time taking notes, it was extremely distracting to her and to me. Current psychiatrist took notes during the first couple of sessions and never since. His sessions are 45 mins. each, back to back, and I think he does brief notes in between, so my session might be a minute or three shorter than otherwise but I know I have his full attention while I'm there, which is much better, especially when discussing really tough things.

My patients hardly notice I take notes. I keep it very brief, discreet... mostly therapy with some med management... (edited for privacy issues)

 

[whopper]

Note should be written in a manner (like a lab manual) where another practitioner can replicate the results and understand what happened.

What I usually see from the majority in private practice is when I get other notes they're horrendous. A problem in our field is once you get the license you can do practice including poor practice and likely get away with it.

To date less than 10% of other doctors I see write good notes. I've met some brilliant doctors who write terrible notes. Their thought process is brilliant but their notes are not. E.g. they're write they started a patient on an antidepressant but not write the dosage, and if they stop a med not write down why.

Smartphrases help if you're using an EHR. This will fill in a lot of gaps for you. Also with my EHR, I simply copy and past the last note and use it as a template for my current note so I don't have to retype much.

 

[WisNeuro]

Smartphrases help if you're using an EHR. This will fill in a lot of gaps for you. Also with my EHR, I simply copy and past the last note and use it as a template for my current note so I don't have to retype much.

Exactly, you should have templates. I do lengthier evals, but I have templates for pretty much everything I need to write up (e.g., AD, Vascular, Lewy Body, psych, malingering, etc). At that point I just need to change the demo info, re-write the specific complaint details, and an individualized summary and recs. Honestly, EHR or not, you should never be writing notes from scratch. If you need to, create some word doc templates and use those.

 

[Bartelby]

It varies for intakes and followups. For followups, write a brief "subjective" section and have a MSE auto-populate and then modify it accordingly. Be telegraphic; for instance "appearance: alert, good hygiene, casually dressed." Have labs, vital signs and the last note's plan all auto-populate (or paste them in as needed); tweak those as needed. For the assessment, actually take time to explain your clinical decision making in full sentences. Think about what you skip to when you read an endocrinologist's note or a neurologist's note: the assessment and plan! Don't lapse into the mistake of saying "Assessment: Depression" and expecting the reader to figure out what you were thinking from the facts presented elsewhere in your note. A followup note like this typically takes me less than five minutes to write, and I frequently get complimented on my note quality (probably because I actually explain what I am thinking instead of expecting the reader to guess at it).

For intakes, a good intake note takes some time to write (I find ~20 minutes is not unusual) unless the patient is very straightforward. I recommend pre-reading about the patient and popping the information into a note template as you do so. After seeing the patient, type in the rest in a somewhat telegraphic way and correct anything that needs updating. Again, in your assessment take time to spell out your thinking. Consider dictating admission notes too; either Dragon or a dictation service can save you time if you develop the skill set (mostly for intake notes; followup notes are short enough that dictating isn't really worth the trouble).

 

[tr]

Yes the meat is in the A/P. Everything else is subsidiary. Assessment should have all the info needed to understand the plan, but no extraneous info as that just makes it harder to find what you need. Made up examples of typical A/P for me would be

"A: 45F presents with 3rd lifetime episode of MDD in context of marital strife. Previously failed multiple SSRIs but did well on Wellbutrin.
P:
-Restart Wellbutrin (dose)
-Referral to couples counseling
-rtc one month"

Or,

"A: 32M with one prior lifetime episode of mania in context of steroid treatment, now presents with second lifetime episode of mania in context of recent international travel and extensive sleep disruption.
P:
- Trial Seroquel (dose) qhs
- Min 8h continuous sleep q night. Implement sleep hygiene recs as discussed in session, including (specific recs)
- Check TSH
- Spouse to assist with maintenance of regular schedule; ROI for (spouse, contact info) signed
-rtc 1 week, sooner if needed"

 

[nitemagi]

write less.

 

[SpongeBob DoctorPants]

I appreciate everyone's feedback; thank you very much!

I do make use of templates I have created, and I am constantly tweaking my autotexts (smartphrases) to make them more efficient, because I still feel like I do too much typing. I also have detailed assessments and plans, and I feel that this part of my documentation is just fine. I have actually been complimented several times by other providers about the amount of detail in my notes, sometimes to the point that I wonder if I have too much detail.

The main section of my note which I think I need to be more effective with is the subjective/history of present illness. As some of you have noted, this is not as important as the assessment and plan, but my understanding is that for billing purposes, this is where you need to have sufficient data to support whichever code you bill (for example, elements such as frequency, duration, severity, exacerbating factors, and so on).

I have been wondering if there would be anything wrong with having a generic HPI template which includes headings such as mood, anxiety, psychosis, behavior, sleep, etc., with default descriptions which state something to the effect of "Normal/No complaints", and if there is something applicable I could just modify the text during the visit.

The way I am doing things right now, I have several autotexts for various diagnoses, and when I open the chart I look at the problem list and start inserting my autotexts for each problem (such as MDD, GAD, ADHD, etc.) into the subjective section, and while talking with the patient I click on drop-down menus I have created or add additional text as needed. When I am through with the encounter, my subjective history may look something like this:

Date
Present for encounter: patient and mother

MDD: Stable, no complaints. No SI since 4 months ago. No SIB.
GAD: Increased over the last 4 weeks. Getting worried about upcoming school year. Worries occur daily. Mild in severity.
ODD: Outbursts increasing. Moderate in severity. Tantrums occur multiple times per day and include yelling, hitting, slamming doors, throwing things. Episodes may last up to 20-30 minutes. Exacerbated by being told no or being asked to stop playing video games.
ADHD: No concerns with focus during the summer as school is out of session. Would like to restart medication when school starts. Was previously taking Concerta 36 mg. Mom is wondering if a higher dose might be needed this school year.
Sleep: Difficulty falling and staying asleep. Bedtime is 10 PM, asleep by 12 AM. Wakes up once a night for 30-60 minutes. Gets up at 10 AM. No daytime naps. Good daytime energy. No caffeine use. Watches TV or plays video games until going to bed.​

When I type the assessment, generally I will summarize information from the HPI and offer my thoughts about what could be affecting the patient's progress, and I may include my opinion on what might be expected from the current treatment plan, or include alternative treatment plans we discussed. For the plan, I have an autotext which includes headings for medications, labs, therapy, and follow up, with drop-down menus for some of these to select different options.

One thing which slows me down is the EMR we use, and our institution requires us to navigate through several tabs and click on various boxes so they can track certain pieces of data, and it is not possible to toggle back and forth between these forms and the note I am writing. It is also not possible to copy forward any previous notes, unfortunately, but I can highlight and copy text from previous notes, which I will modify in the current note as applicable if I choose to go that route.

Anyway, I'm wondering what others may think of the sample HPI included above. For what it's worth, just today I was looking at some notes from another provider, which were extremely brief; they had six progress notes written on each sheet of paper (yes, that's six encounters on one page!), and the notes were essentially no more than a mental status exam and one or two lines of free text. At least they were quick to read.

 

[Liquid8]

For outpatients, my initial intakes are on the lengthier side, mainly for my own benefit so I can review them as a reference just prior to the next appointment. I did try using a template at the very start, but I found that my style of history taking wasn’t mechanically structured in such a way that suited that format. Subsequent reviews tend to be much shorter – roughly structured as Current Meds/Side Effects, New Issues, MSE, Impression, Plan.

Inpatient varies. I’m admitting more of my own patients (ones I know from my outpatient rooms as opposed to fresh referrals that come through the hospital) so I can keep it brief and supplement it with a letter or recent entry from my own notes.

Regarding the brevity of notes, over time one gains more experience and develops more knowledge about what needs to stay in and what can be left out from the record.

 

[tr]

I appreciate everyone's feedback; thank you very much!

I do make use of templates I have created, and I am constantly tweaking my autotexts (smartphrases) to make them more efficient, because I still feel like I do too much typing. I also have detailed assessments and plans, and I feel that this part of my documentation is just fine. I have actually been complimented several times by other providers about the amount of detail in my notes, sometimes to the point that I wonder if I have too much detail.

The main section of my note which I think I need to be more effective with is the subjective/history of present illness. As some of you have noted, this is not as important as the assessment and plan, but my understanding is that for billing purposes, this is where you need to have sufficient data to support whichever code you bill (for example, elements such as frequency, duration, severity, exacerbating factors, and so on).

I have been wondering if there would be anything wrong with having a generic HPI template which includes headings such as mood, anxiety, psychosis, behavior, sleep, etc., with default descriptions which state something to the effect of "Normal/No complaints", and if there is something applicable I could just modify the text during the visit.

The way I am doing things right now, I have several autotexts for various diagnoses, and when I open the chart I look at the problem list and start inserting my autotexts for each problem (such as MDD, GAD, ADHD, etc.) into the subjective section, and while talking with the patient I click on drop-down menus I have created or add additional text as needed. When I am through with the encounter, my subjective history may look something like this:

Date
Present for encounter: patient and mother

MDD: Stable, no complaints. No SI since 4 months ago. No SIB.
GAD: Increased over the last 4 weeks. Getting worried about upcoming school year. Worries occur daily. Mild in severity.
ODD: Outbursts increasing. Moderate in severity. Tantrums occur multiple times per day and include yelling, hitting, slamming doors, throwing things. Episodes may last up to 20-30 minutes. Exacerbated by being told no or being asked to stop playing video games.
ADHD: No concerns with focus during the summer as school is out of session. Would like to restart medication when school starts. Was previously taking Concerta 36 mg. Mom is wondering if a higher dose might be needed this school year.
Sleep: Difficulty falling and staying asleep. Bedtime is 10 PM, asleep by 12 AM. Wakes up once a night for 30-60 minutes. Gets up at 10 AM. No daytime naps. Good daytime energy. No caffeine use. Watches TV or plays video games until going to bed.​

When I type the assessment, generally I will summarize information from the HPI and offer my thoughts about what could be affecting the patient's progress, and I may include my opinion on what might be expected from the current treatment plan, or include alternative treatment plans we discussed. For the plan, I have an autotext which includes headings for medications, labs, therapy, and follow up, with drop-down menus for some of these to select different options.

One thing which slows me down is the EMR we use, and our institution requires us to navigate through several tabs and click on various boxes so they can track certain pieces of data, and it is not possible to toggle back and forth between these forms and the note I am writing. It is also not possible to copy forward any previous notes, unfortunately, but I can highlight and copy text from previous notes, which I will modify in the current note as applicable if I choose to go that route.

Anyway, I'm wondering what others may think of the sample HPI included above. For what it's worth, just today I was looking at some notes from another provider, which were extremely brief; they had six progress notes written on each sheet of paper (yes, that's six encounters on one page!), and the notes were essentially no more than a mental status exam and one or two lines of free text. At least they were quick to read.

I think your sample S section looks good but I find autopopulation very concerning if it's anything beyond labs or MSE headings. It's too easy to accidentally leave in the default and I have seen many notes by other Drs with obvious falsehoods or self-contradictions that are clearly a result of forgetting to modify the autopopulated text appropriately. I've also seen residents falsely document exams they did not do because of using note templates with autopopulated exam findings. Think about what that could look like in court.

 

[OldPsychDoc]

write less.

...smile more.

 

[NickNaylor]

I have a tendency to write long notes that I'm sure nobody reads, but I do feel like if someone at some point in the future goes back to look at them they will be helpful. As others have said, the meat is in the A/P. You can also summarize (briefly) pertinent findings in the assessment.

For plans, I also agree with the comments above. My plans are very detailed, and I include doses for all medications as well as indications. If I'm doing something somewhat weird pharmacologically, I explicit state why in either the assessment or the plan. My goal for my A/P is for someone to be able to read my note and have a clear understanding of what's going on and why I made the choices that I made. Of course, this is more than what's necessary for billing purposes, but my own approach is that notes are there to communicate to other providers what's happening - the billing is secondary and will naturally follow if you write decent notes.