Efficiency, Flow, seeing 2-3 pph and getting documenting done

[migm]

Hi guys,

3rd year resident here in a 3 year program. Ever since I started this lil shindig I've been reasonably fast at seeing patients - in and out on a moderately complex patient in about 5-7 minutes. Of course my residency is at a quartnary center so most patients that have a cold also have a liver transplant, wegener's.. etc. I digress. I can see 2-3 an hour. I can write orders on them. I can dispo them. But for the life of me, I cannot figure out how to fit my notes in there. We use dragon to dictate.

What's your flow that you use? Do you have a rhythm that you get into? Often times I don't have time to sit down and even jot out a quick note as there's another EMS arrival. Sometimes my attending will write the note and to save time I won't write one (I realize when I'm the attending this strategy will backfire in a major way).

Part of my concern is that if I sit down and do say the H&P and leave the MDM off that it will take too long to do and my flow will suffer, but i've never been able to make this system work for me. I end up doing 90% of my notes after my shift, staying 1-2 hours after.

Thoughts?

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[Groove]

2-3pph is a brisk pace and concise notes exercising brevity and relevance are key. There are some variables outside your control such as EMR, ED geographics, network issues, etc.. that might slow you down but you probably just need to work on your notes. You shouldn't have much in your MDM for an abscess, kidney stone, essentially level 1-3's unless it's relevant. Save MDM documentation for 99284,5's. Anyway, personally... I usually pick up 3-4 patients when I get to work and round on all, drop in orders along the way and only after I've seen them all do I stop to put in the notes (all orders should be done by this point). Brief HPI/ROS/PE. I try not to get up to see another until they are documented unless it's a critical pt. Rinse/repeat. Luckily, we have much more scribe coverage these days which speeds up your efficiency. Sometimes, I will knock out 3-4 pt's with the scribe and see 2 more while they are finishing documentation, do those two myself and then we hit another 3. Everyone is different to some degree. You just need to find your happy medium. Some shifts you can't avoid doing some documentation after your shift. Most of the time these days that's primarily finishing my MDM and other misc documentation that takes very little time. Everyone is going to have the occasional shift where you have 20+ in the waiting room and are humping and unable to sit down to document but it shouldn't happen too often.

If you're unable to keep up with your documentation then slow down. Quit picking up patients. When you graduate, you'll be expected to see 2pph comfortably. Anything over that is gravy. Any job that expects you to see 3pph on average....avoid.

Dragon is nice but dictation systems are not going to be the norm while on your job hunt. I'd make sure you graduate feeling comfortable with typing your notes.

 

[link2swim06]

My efficiency gets killed when I have to do a procedure...
I spend 10-15 minutes getting supplies, setting up, consent, etc.
Another 10-20 minutes doing the procedure
Another 5 minutes cleaning up
Maybe another few minutes waiting for a post-procedure xray

I don't really get how you can average 3 pph if you are doing even a handful of procedures a day.

 

[dotcb]

Make time for documentation. It's part of the job. Stable patients can wait a little bit here and there.

 

[Birdstrike]

The difference between 2 pph and 3 pph is huge. With any acuity, to average 3 pph, every shift, day in day out over the long haul, is tough. It is very tough to do safely, document safely, and not miss things and do more than just triage. You're trying trying to see too many. Slow down and cherry pick a few lower acuity ones along the way to make your numbers look better. Heresy, I know, but chances are others are doing this to you anyways and you're getting dumped with higher acuity, dragging your numbers down. You shouldn't be staying late to document. That's a terrible habit to get into.

 

[GeneralVeers]

Generally, while I am documenting on the last patient I saw who is admitted or discharged, I sign up for the next patient and put in orders but don't see them. If it's a RUQ abdominal pain I'll order CBC, CMP, Lipase, and US. That means the workup is in progress while I am documenting on the last patient. I'll see the next patient about 10-15 minutes later and often some of the labs are already back. Rinse, repeat. It really speeds up your efficiency if you put in orders before you see the patient. A 75 yo with CAD and chest pain will be an automatic admit. I order the EKG, CXR, POC Troponin and CBC before even seeing the patient. Often X-ray is waiting for me to leave the room. I can get a typical elderly CP admitted in about 35 minutes.

 

[LaBusqueda]

One thing that I found made a huge difference is learning to get rid of dead time.
In residency and right out of the box I would be in a EMS Pts room even before the nurses, or I would be in a resus room way too long before a code. That is time that I could be charting, ordering, dispo etc.
I realized (and maybe it was just a me thing) that most 99.9999% of Pts can wait until I was able to get to them. If I was in a task, I completed it. If I was planning a dispo, do it, then go in.
If your shop is any good, your nurses will let you know when you are needed. And if they LIKE you, even more so.

The type of practice you end up in will matter a LOT! So think about this and talk to docs where you interview.

 

[migm]

My efficiency gets killed when I have to do a procedure...
I spend 10-15 minutes getting supplies, setting up, consent, etc.
Another 10-20 minutes doing the procedure
Another 5 minutes cleaning up
Maybe another few minutes waiting for a post-procedure xray

I don't really get how you can average 3 pph if you are doing even a handful of procedures a day.

No doubt - a lac repair, LP, para, central line all slow me down. My experience is similar to yours: It can take 20 minutes just to get the stuff, get the lido, prep the patient, wash the wound and start to suture. Not to mention getting the pt out of a hall into a room so my elbow doesn't get bumped while I'm suturing. A lot of what we see based on how our pods are is a ton of fast track stuff with some complex patients acute on chronic stuff mixed in with the occasional critical patient. Our ED, not unlike others, stuffs patients were there are beds.

At least at my residency the stuff you'll need isn't there for you the vast majority of the time - I think a lot of time could and will (according to the my community experience so far) be saved by letting the doctor do the things that doctors do and letting someone else deal with rounding up all the moving parts to let the procedure go forward.

 

[migm]

One thing that I found made a huge difference is learning to get rid of dead time.
In residency and right out of the box I would be in a EMS Pts room even before the nurses, or I would be in a resus room way too long before a code. That is time that I could be charting, ordering, dispo etc.
I realized (and maybe it was just a me thing) that most 99.9999% of Pts can wait until I was able to get to them. If I was in a task, I completed it. If I was planning a dispo, do it, then go in.
If your shop is any good, your nurses will let you know when you are needed. And if they LIKE you, even more so.

The type of practice you end up in will matter a LOT! So think about this and talk to docs where you interview.

Agreed this is definitely part of my problem. I have white board anxiety - as soon as I see the new patient moving back I lose focus on whatever I'm doing and am interrupted in doing a quick chart scan, reading the triage, looking them up in the narc database, yadda yadda, partly because I find documenting dreadful and partly because I want to get in and get the ball rolling on the new patient.

Can you clarify your final two sentences? I think it's an important point but I wonder if you could expand on what you're getting at a bit.

 

[emergentmd]

I work at a referral center and get everything but major trauma. We do all of our own computer charting and order entry. No scribes. We have a fast track with midlevels so they take everything that doesn't require a work up.

I feel that if I see 2/hr its a leisurely day. 3/hr and I feel like I am pushing it for the whole 8 hr shift. Unless there is so complicated procedure, I can finish all of my charting when seeing less than 3/hr. At about 3.5/hr, ALL of my charting is put off until my 8 hr shift is done. That leaves me about 2 hrs worth of homework.

I prefer to see 2.5/hr b/c I know my charts will almost be done by the time I have to leave and I feel productive. I tend to always be fast at seeing pts/charting and would say that I am the top 3 at my ED. What makes me efficient/fast without taking shortcuts are.

1. Have a clear plan right after initial pt visit. That means I ORDER everything I need including meds and rarely have to go back to reorder stuff other than pain meds. After 60-90 minutes, all Labs and imaging is back. At that time my decision is made to discharge vs admit. There is no middle ground. I rarely have to reevaluate the pt before my 2nd and final visit. All of my pts know this. I tell them up front that everything will be back in 2 hrs and I will come back with a plan. They are happy with this, I rarely get complaints, I do not have to have needless revisits other than the exception.
Example - Chest pain. Order everything, admit or not. I do not do 2nd set of troponin, or second set of anything. I do not do chest pain obs. I do not go back to ask any more questions. I come with results/plan and let the pt decide to stay if I think admission is warranted. I never understand docs keeping pts in the ED for 4-6 hrs to do serial tests. This is the ED, I DO NOT do serial anything.

2. I do not write down any notes. I have a sheet with all my patients demographics. The only thing on that sheet is labs ordered/EKG & CXR finding. Once I have all of my boxes checked, I am back for disposition. I remember all of the important parts of the history/physical and EVERTHING else on the chart will be a normal finding. Thus on most patients, I have to remember 2-3 key points and that is it. If I forget something, I can get it from the triage note. Does it really matter if their leg has been hurting for 2 vs 4 dys? I see some docs stay in the pts room for 15 minutes all of the time and come out with a whole page of notes. I don't get it. I am in the room max 5 minutes, I do not write down a single note. I come back to my desk with my patient demo sheet and put down what I ordered. This has helped me to see 8 pts comfortably in the 1st hr and also see 15 pts in my 1st hr (which is my record)

3. I do hourly lab round. Once an hr usually unless I it is slow and I am bored. If I am busy, my rounds maybe every 90 minutes. But I check them usually every hr. Why? B/c I catch when something has not been done and will not be surprised. Everyone is on a plan to be discharged vs admitted. By my 2nd lab round everything should be back, and if not, I have already asked the nurse to check on why they have not completed their tasks. I find too many doctors no checking for hours and then being flustered that something wasn't done. I feel I have to treat nurses like my kids sometimes with constant reminders. They sometimes think a U/A may not be needed or the pt did not want to urinate. Not in my world. If I need it and on my 1st lab round it is not in lab, I tell them to CATH the pt. This usually promote urine one way or the other.

4. I am a fast charter. Figure it out. If you are slow, find a way to fix it. There is always a solution to whatever admin present to me. Some docs complain, I just find fixes. I have realized that complaining fixes very little. I have unorthodox solutions sometimes, but can computer chart a pt in 2-5 minutes.

5. Plan a home get away. I love my job but am not paid to stay to chart. I am not paid to wait on CT scans. I love my family and want to be home to spend it with my family. 2 hrs before my shift ends, I check EVERYTHING to make sure it is done and nicely tell whoever is responsible to do their job. Thus at 1 hr mark, everything should be cooking and I am on my way to going home. I will call the radiologist to push my studies up. I will page or text my consults/admission. If they have not called me back by the time I am leaving, I will text them my cell phone number. I see docs staying around waiting for phone calls which can be an eternity. My time is as valuable as the consultants. Nothing wrong with them calling me on my cell phone.


6. My and Your time is valuable. We are ED docs. We are paid either by the hour or RVU. Staying later b./c labs were not done or people not calling me back adds nothing to patient care or my income. Thus, my day consists of making sure everything is on track to dispo a pt and for me to go home close to when the new guy comes in. Many docs I work with is surprised that I usually leave on time even when I see 3 pts/hr. I am sure they think I am slacking but when the numbers comes out, I am always top 3 RVUs. I am not trying to boast, its just the facts of EM.

 

[Hercules]

Even better than putting in your own preorders is to train your nursing staff up to do it.

As far as procedure set up time, that will disappear in private practice. Your staff will set up your procedures for you.

 

[Angry Birds]

During residency, you are competing (in a good way) with your colleagues: whoever sees the most patients (in a safe way) gets a certain amount of respect. You certainly can't be one of the laggers, i.e. not pulling your weight. Because of this, I remember in my residency that I didn't give heavy emphasis on "live" dictation/documentation... Instead, I'd always play catch up during downtime and/or 30 minutes before the shift ended.

That is, however, a very stressful way of doing things... especially if you want to get out on time (and you should always aim to do that, or at most stay an extra 30 minutes after your shift--any more than that and you risk looking inefficient).

As an attending, I work at a solo-shop so I do things differently. Now, I see a patient and complete their chart before seeing the next patient. I even do MDM as much as I can. Being militant about doing the chart BEFORE going to the next patient has made my quality of life improve immensely, since there is not that stress about being 10 charts behind.

I know people did this system in residency, and maybe it's good to start then...although I never did for the reasons stated above.

 

[da8s0859q]

OP, similar situation here. PGY3, have Dragon and Epic.

Unfinished documentation causes me more angst than a chart in the rack does.

My routine:
- Pick up patient, glance at chart for pertinent stuff. Know as much of relevant history as possible before I go to the room.
- Bedside eval.
- Orders. Includes strictly PRN orders so as to save time and clicks later (e.g., repeat pain med doses; antiemetics for someone not nauseated now but might be later). Diet orders when I'm convinced someone can or can't eat/drink regardless of workup results. Saves both me and RN/PCA staff time.
- Do note, including HPI/ROS/PE, with any reminders of what I want in my MDM in the MDM section. Occasionally pre-dictate an MDM (the x-ray is almost certainly going to be negative, supportive care, why it isn't what it isn't, etc) when I suspect I know how diagnostics are going to go. Tend to be a touch verbose in MDMs, so have gradually been shaping how I dictate to be concise yet appropriately thorough.
- Repeat.

Between charts, especially if the rack is empty, finish an MDM on someone I discharged (or especially admitted). If the rack is empty, pre-emptively do discharge stuff on someone I expect to discharge pending tests and/or repeat evaluation. Every so often, look back at how I'm doing things and find ways to be better in some way.

The relative peace of mind that comes with not having a bunch of charts on which I haven't even started a note is worth more to me than seeing an extra few patients a shift and feeling far more harried and stressed out all shift long. The times I've tried the opposite approach, that's been about the difference. I am a stickler about documentation and make every MDM (a) briefly paint a picture, and (b) something I would be glad I said if I were reading it prior to a deposition one day.

I, of course, defer to our SDN attendings for more experienced advice.

 

[The White Coat Investor]

First, realize that 2-3 patients per hour on average over your shift is a very fast pace, so don't feel bad that you find it difficult. So do I. That's 16-24 patients in an 8 hour shift. To see 24 and walk out right at the end of a shift would be an impressive accomplishment in my shop. I've often see 2-3 patients per hour for many hours of my shift, but not on average. In order to average that, you probably have hours where you are picking up 4-6. It can be really tough to move at that pace and do your documentation as you go along. So acknowledging that I'm moving at a slower pace overall than you are, here is my most efficient practice:

1) Pick up patient on the EMR while still in the waiting room. If orders are obvious, I place most of my orders now before ever laying eyes on them. I can do most of the orders for 3/4 of my patients based on the nursing notes. I usually have to add a couple more after seeing them, of course. At this point I also glance at their previous visits to our ED and if a painful complaint or other red flags, look at their controlled substance database report.

2) Go see the patient as soon as they're roomed and do the H&P. I write fewer than 10 words while in the room (name of their OB, dose of pertinent meds, that sort of thing that I won't remember in 2 minutes.) Then I return to the workstation, and document the entire visit except for the discharge instructions and the ED course. Add any additional orders. Go see next patient and start over.

3) Check in on patient at some point in the visit.

4) See patient at time of discharge, go over instructions verbally and agree on plan. Then finish documentation and print it out. Patient goes and chart is done. Total time per patient for a typical patient is probably in the 20 minute range if there are no procedures involved. So if they're lined up perfectly, then yes, I can see 3 pph. But they don't line up like that typically so my average is far lower.

 

[The White Coat Investor]

And help the nurses help you to be efficient- that means prioritizing dispositions over new patients. Shotgun orders 90% of the time. A patient that is not in the department is not sucking up nursing staff and resources getting blankets, drinks, more doses of pain/nausea medication etc. Disposition first.

Decide if they're a drug seeker or not at the beginning of the visit so the patient, the nurse, and you are all on the same page about how you're going to treat their pain.

 

[emergentmd]

During residency, you are competing (in a good way) with your colleagues: whoever sees the most patients (in a safe way) gets a certain amount of respect. You certainly can't be one of the laggers, i.e. not pulling your weight. Because of this, I remember in my residency that I didn't give heavy emphasis on "live" dictation/documentation... Instead, I'd always play catch up during downtime and/or 30 minutes before the shift ended.

That is, however, a very stressful way of doing things... especially if you want to get out on time (and you should always aim to do that, or at most stay an extra 30 minutes after your shift--any more than that and you risk looking inefficient).

As an attending, I work at a solo-shop so I do things differently. Now, I see a patient and complete their chart before seeing the next patient. I even do MDM as much as I can. Being militant about doing the chart BEFORE going to the next patient has made my quality of life improve immensely, since there is not that stress about being 10 charts behind.

I know people did this system in residency, and maybe it's good to start then...although I never did for the reasons stated above.

There is no way to do this in a busy ED. You walk in, there is 6 to be seen and 4 to be put back. You see one, spend 5 min charting. See another spend 5 min charting. By the time you see the 10th pt, there is 5 more checked in.

NO way this works in my shop. Any doc that does this puts their colleague in a difficult situation and will be talked to

 

[Angry Birds]

There is no way to do this in a busy ED. You walk in, there is 6 to be seen and 4 to be put back. You see one, spend 5 min charting. See another spend 5 min charting. By the time you see the 10th pt, there is 5 more checked in.

NO way this works in my shop. Any doc that does this puts their colleague in a difficult situation and will be talked to

That makes sense.

I work 24 hour shifts at a rural hospital. I'm the only doc on and the volume is nowhere near that. It's still much busier than I expected, but not the insane pace that was residency. Thank God.

 

[emergentmd]

The way EM medicine is going, you have to see pts before charting. Everyone will look at metrics and if your metrics shows that you are a slow doc, you will be watched. There is no way to chart when pts are to be seen.

Docs asks me for pointers. I always say

1. Order everything first. No nickle and dimeing orders. You will suffer. Nurses hates you. Patients suffer

2. If you question if you should order a CT vs abd U/S. Do a CT. Even if I think its gallbladder, I Rads can tell me if there is cholecystitis 95% of the time. Much faster to get a CT than U/S

3. CT without rather than CT unless there is a real need. I do not like to wait for the creatinine for a CT with IV. You can get 95% of the diagnosis with CT without. Even when the CT has some questions, rads will almost always tell me that IV would not have helped. I almost never order oral contrast.

 

[USCDiver]

I try to document as I go for the most part (aside from the 3-4 patients seen right away at the beginning of the shift), but more importantly is my personal axiom: no one gets a dispo without their chart being done. If it is a discharge, the chart is done before instructions and prescriptions are printed. If it is an admission, the note gets done as soon as I've put in the page, hoping to get a callback while I'm still finishing the chart.

 

[Droperidol]

Flow will depend largely on your infrastructure. We have epic and scribes. I typically will pick up 6-12 patients per hour in the first two hours depending on how busy it is. Then as the dispositions come in I have to slow way down. I prioritize dispos first before picking up new patients. As I go I dictate much of the mdm to the scribe. The scribes complete and print AVS while I get prescriptions ready. As they put up the paperwork or I admit the patient, I will tidy up if needed and or add complex mdm and then sign chart. I spend 1-2 min max documenting myself. I avg 3-3.5 pph in an 8 hour shift over the month. I admit 20% of patients. I leave usually around 15 min after shift unless something extraordinary comes up. I also route calls to my cell if I'm waiting for a consultant at the end and log in remotely to update that specific chart. You can get extremely efficient at documenting with tricked out epic dot phrases with appropriate modifications and a good scribe.


Sent from my iPhone using Tapatalk

 

[emergentmd]

I try to document as I go for the most part (aside from the 3-4 patients seen right away at the beginning of the shift), but more importantly is my personal axiom: no one gets a dispo without their chart being done. If it is a discharge, the chart is done before instructions and prescriptions are printed. If it is an admission, the note gets done as soon as I've put in the page, hoping to get a callback while I'm still finishing the chart.

I do not see any way of charting everything before discharging pt or admitting pt. If its a slow ED, sure. If you are in a Busy ED, Impossible unless you want to put your partner in a bad spot. Don't be that Doctor.

 

[xaelia]

1. Dispo first. Yes, time-to-physician is tracked, but so is LOS. The five minutes you use to finish discharge instructions are quicker than the 10-15 minutes you spend with a new patient.
2. When tests = revenue, it's easy to do more. This will change; soon, every test is money out of your/group/system's pocket. And, frequently, more tests beget more tests, more consults, and more hassles. Fewer tests means shorter LOS. I do fewer tests.
3. Very hard to compare pph numbers with strangers on the Internet. Where I work, it's structured such that acuity, documentation, and care coordination makes 2 pph a brutal day.

 

[namethatsmell]

Very hard to compare pph numbers with strangers on the Internet. Where I work, it's structured such that acuity, documentation, and care coordination makes 2 pph a brutal day.

Quite true.

At our county shop there's an urgent care side that siphons off all the level 4s and 5s so in the main ED the acuity is very high. Seeing 1.8-2pph while doing a thorough job is hard.

Meanwhile at the small town shop I'm moonlighting at seeing 2.5-3/hr is very doable even for a lowly resident like me as the acuity is variable and hand pain/arm pain is a dime a dozen.

For other residents out there consider this: there's a difference being the fastest in your class and "seeing" 2.5/hr but missing stuff and having your attending or admitting service catch/handle your missteps. Yeah you may appear to be a boss on the tracking board but people will readily notice when many of your plans consistently fall short. Better to be in the middle of the pack but have all your patients tightly managed. But what do I know I'm just a biased resident.

 

[Angry Birds]

For other residents out there consider this: there's a difference being the fastest in your class and "seeing" 2.5/hr but missing stuff and having your attending or admitting service catch/handle your missteps. Yeah you may appear to be a boss on the tracking board but people will readily notice when many of your plans consistently fall short. Better to be in the middle of the pack but have all your patients tightly managed. But what do I know I'm just a biased resident.

It's important not to be a laggard. Being in the middle of the pack is just fine, especially if you manage your patients tightly.

Also, I think some/many people exaggerate how many patients they see per hour.

 

[namethatsmell]

It's important not to be a laggard. Being in the middle of the pack is just fine, especially if you manage your patients tightly.

Also, I think some/many people exaggerate how many patients they see per hour.

Yeah I'm basically going off the advice from the fastest attending I've ever worked with (seriously, the guy is a total beast): basically, it takes seeing ~10k patients (or more) to become diagnostically/therapeutically efficient and efficacious. The way to become really fast is to spend those first 10k encounters learning as much as you can and streamlining things along the way. Yes you should push yourself to see a good number of patients but not to the point where you're just moving the meat as fast as you can, especially as a resident/brand new attending.

 

[LaBusqueda]

On my last couple of sentences, your department type (academics, community, single coverage, fast track, etc.) will matter incredibly. Others have eluded to this already.
I also always rec when you interview for a job, find the contact info of a couple of docs not interviewing you (if applicable) and talk to them and ask questions about the job. You will sometimes be surprised at what you find out.

 

[alpinism]

Quite true.

At our county shop there's an urgent care side that siphons off all the level 4s and 5s so in the main ED the acuity is very high. Seeing 1.8-2pph while doing a thorough job is hard.

Meanwhile at the small town shop I'm moonlighting at seeing 2.5-3/hr is very doable even for a lowly resident like me as the acuity is variable and hand pain/arm pain is a dime a dozen.

For other residents out there consider this: there's a difference being the fastest in your class and "seeing" 2.5/hr but missing stuff and having your attending or admitting service catch/handle your missteps. Yeah you may appear to be a boss on the tracking board but people will readily notice when many of your plans consistently fall short. Better to be in the middle of the pack but have all your patients tightly managed. But what do I know I'm just a biased resident.

Exactly.

Hate to say it but anyone seeing over 2 pph is essentially working with urgent care (medium to low acuity) patients all day.

No way you can safely see that many in a high acuity shop with multiple major traumas, medical resuscitations, and procedures every shift. Especially as a PGY1/2. Not to mention I still like sitting down and spending at least 5-10min talking to patients explaining my differential/concerns and including them in the decision making about which labs/imaging to order.

Yet another reason why I could never do community EM.

 

[Janders]

Its all about marginal gains.

The basic tenants of personal ED speed (Dispo FIRST, Order all tests at ONCE if possible, smart triage-RN driven testing from WR, wise use of templates/EMR) and system ED speed (rapid admit-to-floor times, streamlined lab and radiology, eliminating old-fashioned bottle-necked single-nurse triage booth, etc) are well established.

You should actively work on the first part. You should encourage your hospital/system to work on the second.

I'm pretty darned quick in the ED. My charting is less quick, still decent. I saw 26 in 8 hours yesterday (just over 3/hr), plus supervised 8 PA cases (all fast-tracky)... thats >4/hr total. I can do that safely, but I can't keep up on the charting... stayed 90 minutes late to chart. 'tis Ok though, as I had an admin meeting scheduled 90 minutes after my shift ended

 

[Hercules]

Exactly.

Hate to say it but anyone seeing over 2 pph is essentially working with urgent care (medium to low acuity) patients all day.

Yet another reason why I could never do community EM.

Always good to not make bold sweeping statements in these discussions as it may sometimes reveal ignorance. As multiple posters have noted, a lot of your pph has to do with how efficient your system is as much as how efficient your doctor is. I'm at a near perfect efficiency shop. We have high functioning nurses, a good EMR, scribes, great midlevels, a high functioning hospitalist service, and a supportive admin. I worked yesterday and saw 24 patients in an 8 hr shift, 13 midlevel patients (we see each patient they do-- not just sign charts after the fact) and I left on time at the end of my shift with all charting done. I am not the fastest doc in my group. We have a 20% admit rate and 5-7% critical care so it's definitely not all urgent care patients. In fact with the PAs cleaning up the urgent care patients our individual admit rates and critical care rates are actually higher than that. I have worked in other places where I was breaking my neck and swimming up stream to try to see >2 pph because the system was so bad.

 

[Docinthetrenches]

Choosing a job where they want you to see more than 2 patients per hour (non urgent care that is) is a sure fire way to burn out after a few years. Having to stay late to do charting or having to it remotely from home after your shift is also a nightmare and guaranteed to drive you crazy. I personally shoot for 2 per hour and that's including charting. I usually get close or over slightly. You'll be better at fast charting but eventually if you want to see more, you will probably need a scribe.

 

[USCDiver]

I do not see any way of charting everything before discharging pt or admitting pt. If its a slow ED, sure. If you are in a Busy ED, Impossible unless you want to put your partner in a bad spot. Don't be that Doctor.

Just because you can't see a way doesn't mean it isn't possible. Don't be THAT doctor. I can bang out a chart in 3-4 minutes easy. Most shops are going to be looking at ~2pph. Even at 3pph ( which is insane and unsafe in any department with reasonable acuity) you've got 20min total to spend on each patient. So you're looking at spending 10-15% of your time charting. Find those 3-4 minutes while other things are happening around you. Waiting for a call back? Rooms all full and the nurses haven't gotten those two discharges out the door yet? Nurses are having shift change and nothing is getting done anyway? Get your H&P done on those last few patients you just saw, you can buff the MDM at the end of their visit.

I'm not the fastest person in my group, however I'm in the top 30% usually, and I almost NEVER stay late to chart. My record so far is a 9 hour Fast Track shift where I saw and discharged 45 patients (plus another 8-10 who got MSE and moved to the back). Do the math, that's 5-6pph. That's low acuity admittedly but at the end of the day very note was done before the discharge button was pushed and I walked out the door at 9hrs and 1 min.

 

[justaregularmed]

I'm still a trainee but I find that just focusing on the charting is a bit nearsighted about the problem. I find that I can see a bajillion patients in an hour but eventually I will have a critical mass of undispositioned patients that will lead to endless suffering for me and constant disruption of my workflow. So either manage this with your nurses to fend off the wolves or I find that having a disposition of your patients as soon as possible is key. This leads to a compromise between thoughtful care or slashing and burning. I also found that being more efficient with my time helps a lot if you are sitting at the computer you are either following up on results, charting or seeing new patients, its easy to sit at the computer and feel paralyzed. Over an entire shift these minutes matter.

 

[emergentmd]

Just because you can't see a way doesn't mean it isn't possible. Don't be THAT doctor. I can bang out a chart in 3-4 minutes easy. Most shops are going to be looking at ~2pph. Even at 3pph ( which is insane and unsafe in any department with reasonable acuity) you've got 20min total to spend on each patient. So you're looking at spending 10-15% of your time charting. Find those 3-4 minutes while other things are happening around you. Waiting for a call back? Rooms all full and the nurses haven't gotten those two discharges out the door yet? Nurses are having shift change and nothing is getting done anyway? Get your H&P done on those last few patients you just saw, you can buff the MDM at the end of their visit.

I'm not the fastest person in my group, however I'm in the top 30% usually, and I almost NEVER stay late to chart. My record so far is a 9 hour Fast Track shift where I saw and discharged 45 patients (plus another 8-10 who got MSE and moved to the back). Do the math, that's 5-6pph. That's low acuity admittedly but at the end of the day very note was done before the discharge button was pushed and I walked out the door at 9hrs and 1 min.

I am not going to compare how fast you are or if it is possible to always chart before disposition. Also 45 pts fast track if you are only giving out amoxicillin is not much in 9 hrs. Been there, done that. I have hit 40 doing a 9 hr shift with the last 3 in fast track. But this is not the point.

My point is if you ALWAYS chart bf discharging/admitting someone, you will put undue burden on your partner esp when its busy. On slow days, chart to your heart content. If its a busy day and everyone is seeing 3-4 Non Fast track pts/hr, then there is no way you are pulling your load. If you just came on shift, and there are 6 pts to be seen , another 10 behind them, and your partner just picked up 6 new pts in the last hr then YOU are expected to pick up everything for the next hour.

That means, picking those 6 up, and the next 5 coming down the line. While your partner is fighting to get out of his hole, and you just saw your 1st pt that just requires a prescription for an allergic reaction, it is not appropriate to sit there even for 5 minutes charting before seeing the next pt.

Maybe at your shop, but that will not fly at many busy EDs where the goal is to clear out the ED before charting.

 

[The White Coat Investor]

I am not going to compare how fast you are or if it is possible to always chart before disposition. Also 45 pts fast track if you are only giving out amoxicillin is not much in 9 hrs. Been there, done that. I have hit 40 doing a 9 hr shift with the last 3 in fast track. But this is not the point.

My point is if you ALWAYS chart bf discharging/admitting someone, you will put undue burden on your partner esp when its busy. On slow days, chart to your heart content. If its a busy day and everyone is seeing 3-4 Non Fast track pts/hr, then there is no way you are pulling your load. If you just came on shift, and there are 6 pts to be seen , another 10 behind them, and your partner just picked up 6 new pts in the last hr then YOU are expected to pick up everything for the next hour.

That means, picking those 6 up, and the next 5 coming down the line. While your partner is fighting to get out of his hole, and you just saw your 1st pt that just requires a prescription for an allergic reaction, it is not appropriate to sit there even for 5 minutes charting before seeing the next pt.

Maybe at your shop, but that will not fly at many busy EDs where the goal is to clear out the ED before charting.

I just want to point something out. Either you're an employee and somebody is seriously raping you, you have a terrible payor mix, or you're raking in the dough. If there are 16 patients waiting and your partner picked up six in the previous hour, why are there not more docs on duty? No way my group would practice like that. It sounds burnout inducing.

 

[n2b8me]

Its taken me over 10 years out to figure this one out. But the ABCs in ER actually stand for "Always Be Charting" !

 

[emergentmd]

I just want to point something out. Either you're an employee and somebody is seriously raping you, you have a terrible payor mix, or you're raking in the dough. If there are 16 patients waiting and your partner picked up six in the previous hour, why are there not more docs on duty? No way my group would practice like that. It sounds burnout inducing.

We are a busy ED but nothing out of the norm than many of the other EDS I have worked out. All EDs have slow times and fast times. Although this is not the norm, there are times when 15+ pts checks in within 1-2 hrs. I would say this happens once a day. Therefore, we do not staff for a Rush. We deal with it, people see pts quickly, we chart later.

 

[UnderwaterDoc]

To the OP

I work at a busy, medium-acuity level 1, I'm the fastest doc with average 2.6 pph although many days it is closer to 3 pph. My dispo times average in the low 30 minutes. We have scribes but I don't use them as I realized that they just slow me down. I ALWAYS finish my notes before leaving. We have EPIC and Dragon. Here's my work flow.


1- Pick up several charts, 5 at most, go over all vitals/medical history/triage notes/past visits/etc, write in piece of scrap paper room number and chief complaint.

2- Get up and see all 5.

3- Come back to desk and write all orders.

4- Discharge those that aren't getting a workup and put them up in the rack.

5- NOW I document, patients already dispo'd I do the whole note in one sitting and those that are still cooking I do everything plus first half of MDM. Finish MDM after final dispo. I usually will not pick up any new ones until all 5 have been documented, unless something critical comes in.

6- Rinse and repeat, and I ALWAYS run my list before I pick up more patients to dispo as I go.


With this strategy I end up carrying a maximum of 5-8 active patients at a time and getting all my notes done.


I will say that I have many EPIC smartphrases and order shortcuts that I use on a regular basis, and I have gotten very good at saying a lot with few words. Also, our nurses are amazing and they do all consents/get everything ready for procedures/etc so I spend minimum amount of time doing that.

I hate documenting with every fiber in my body but it is the only defense that we have when **** hits the fan. Take the time to do it right. Just come up with the strategy that works for you and stick to it. It gets better with time.

 

[GeneralVeers]

I agree with the above strategy, except that I start orders BEFORE I see the patients if it's clear what the workup will need to be from the CC and nursing note. Sometimes I have a POC troponin resulted by the time I've finished talking with a chest pain patient, and they are ready for admission in less than 20 minutes. I'm also one of the faster docs, and almost never carry more than 5 patients at a time. If I get to 5, I start running my list to see who I can dispo. I'm not sure why so many of my colleagues will routinely have 8-10 active patients, but be less productive, AND stay after their shifts to document. In fact, I'm not sure what they are staying late to document since most of them rely 100% on scribes and don't document any free-text MDM (hence their charts are worthless to figure out what was actually done).

I free-text MDM, just a short paragraph on most patients which summarizes why they came, what I was concerned about, the results of the workup, and dispo. I'm able to do this, and leave my shift on-time or early.

 

[Birdstrike]

Just don't be the slowest one or two docs in a group (or three in a large group) on average. The focus will always be in that "slow guy." Stay somewhere on the middle of your group pph and rvu/hr average and you'll be fine.

If you're the slowest, you're "that guy." Don't be that guy (even though someone had to, and will be).

If you're the fastest, you're probably putting yourself at risk for burnout, or could slow down a little and be a little more careful.

Work to the mean.

 

[The White Coat Investor]

We are a busy ED but nothing out of the norm than many of the other EDS I have worked out. All EDs have slow times and fast times. Although this is not the norm, there are times when 15+ pts checks in within 1-2 hrs. I would say this happens once a day. Therefore, we do not staff for a Rush. We deal with it, people see pts quickly, we chart later.

We all have rushes. But there are people on this thread who are consistently seeing 2.5-3 patients per hour. I know what I make seeing 1.4 an hour with a halfway decent payor mix. I'm presuming those folks are generating twice as much revenue as I am. So my question is where is the money? Are they actually making twice what I am? Per the surveys, I'm at the 75th percentile for income while working 25th percentile hours. Those guys must be off the charts. Or else their employer is killing them and skimming a massive chunk off the top. Or else the patients aren't paying. It can't be any other way.

A "rush of 15 people" is an entire extra shift of patients. I can have a great income and a great life seeing 15 patients a shift for the rest of my life.

My other point is that there is a certain amount of work that must be done for every patient. Barring a life threatening emergency, I try to do that work in the order in which I am most efficient as often as I can (since I am the most expensive cog in this machine.) That means chart done prior to the patient leaving the department. When it's really busy can you lower door to doc times and lower door to dispo times by charting after your shift? Sure. But I think it makes me less efficient over all and certainly makes my charting worse.

 

[Birdstrike]

I can have a great income and a great life seeing 15 patients a shift for the rest of my life.

...if you can keep that contract the rest of your life.

 

[Hercules]

When it's really busy can you lower door to doc times and lower door to dispo times by charting after your shift? Sure. But I think it makes me less efficient over all and certainly makes my charting worse.

I agree with this. Delayed charting results in worse charting and is often less efficient. Also, when people quote patients per hour it's often done incorrectly-- if you saw 24 patients in an 8 he shift but stayed 2 hrs late to chart and dispo then you didn't see 3 pph. You saw 2.4 pph which is still good.

As to your other points, I completely agree that collections per patient is the even bigger metric that none of us openly discuss. Obviously if doc x collects $100/pt and doc y collects $200/pt, then the pace they need to maintain to make a good hourly rate are vastly different.

 

[USCDiver]

Maybe at your shop, but that will not fly at many busy EDs where the goal is to clear out the ED before charting.

I'm not going to get into a pissing match with you, but if you can't keep up with your charting enough without being a burden on your colleagues then that is your problem. The OP was asking about strategies to get his charting done without having to stay late and I offered my advice. I agree with everyone if you're regularly seeing >2.5pph in a high acuity setting then you need better coverage in your ED.

 

[emergentmd]

We all have rushes. But there are people on this thread who are consistently seeing 2.5-3 patients per hour. I know what I make seeing 1.4 an hour with a halfway decent payor mix. I'm presuming those folks are generating twice as much revenue as I am. So my question is where is the money? Are they actually making twice what I am? Per the surveys, I'm at the 75th percentile for income while working 25th percentile hours. Those guys must be off the charts. Or else their employer is killing them and skimming a massive chunk off the top. Or else the patients aren't paying. It can't be any other way.

I do not see how you can see 1.4/hr and make at the 75% tile. What income chart are you using for the 75%? I have worked at private groups and as such had all of the financial info. I would say our payer mix is probably avg. I would say we saw 2.25-2.5 on average. Looking at the charts that are thrown around, we made at the 99%. If you cut me down to 1.4/hr, there is no way we would even be at the 50%.

If you have such a great payer mix/collection/income, keep it as long as you can. If I ran your group, I would push it to 1.8-2/hr and bump you up to the 99%. Pretty amazing income/pp.

 

[UnderwaterDoc]

I agree with the above strategy, except that I start orders BEFORE I see the patients if it's clear what the workup will need to be from the CC and nursing note. Sometimes I have a POC troponin resulted by the time I've finished talking with a chest pain patient, and they are ready for admission in less than 20 minutes. I'm also one of the faster docs, and almost never carry more than 5 patients at a time. If I get to 5, I start running my list to see who I can dispo. I'm not sure why so many of my colleagues will routinely have 8-10 active patients, but be less productive, AND stay after their shifts to document. In fact, I'm not sure what they are staying late to document since most of them rely 100% on scribes and don't document any free-text MDM (hence their charts are worthless to figure out what was actually done).

I free-text MDM, just a short paragraph on most patients which summarizes why they came, what I was concerned about, the results of the workup, and dispo. I'm able to do this, and leave my shift on-time or early.

Agree with all this, and I have a very similar story in my shop. The people that carry the most active patients are the slowest by far. Dispo is the name of the game and you have to do it as you go otherwise you will definitely get overwhelmed once you break the 10-active-patient-barrier.

I forgot to mention above that when it really gets busy (we see 100K+ patients per year) our nurses enter basic orders in triage so a lot of the times labs/xrays will be resulted when I see the patients (or at least the results that matter for disposition).

 

[UnderwaterDoc]

We all have rushes. But there are people on this thread who are consistently seeing 2.5-3 patients per hour. I know what I make seeing 1.4 an hour with a halfway decent payor mix. I'm presuming those folks are generating twice as much revenue as I am. So my question is where is the money? Are they actually making twice what I am? Per the surveys, I'm at the 75th percentile for income while working 25th percentile hours. Those guys must be off the charts. Or else their employer is killing them and skimming a massive chunk off the top. Or else the patients aren't paying. It can't be any other way.

A "rush of 15 people" is an entire extra shift of patients. I can have a great income and a great life seeing 15 patients a shift for the rest of my life.

My other point is that there is a certain amount of work that must be done for every patient. Barring a life threatening emergency, I try to do that work in the order in which I am most efficient as often as I can (since I am the most expensive cog in this machine.) That means chart done prior to the patient leaving the department. When it's really busy can you lower door to doc times and lower door to dispo times by charting after your shift? Sure. But I think it makes me less efficient over all and certainly makes my charting worse.

It sounds like you have a dream job.

Unfortunately those are few and far between. I don't think I am making twice what you are, my hourly rate is 215ish. I work for the biggest CMG so I'm sure they are skimming a boatload. In my geographical area there is no choice but to work for a CMG since they control 99% of the contracts within 100 miles, and the couple of smaller groups left are notoriously toxic, and no I'm not moving

 

[The White Coat Investor]

It sounds like you have a dream job.

Unfortunately those are few and far between. I don't think I am making twice what you are, my hourly rate is 215ish. I work for the biggest CMG so I'm sure they are skimming a boatload. In my geographical area there is no choice but to work for a CMG since they control 99% of the contracts within 100 miles, and the couple of smaller groups left are notoriously toxic, and no I'm not moving

I do have a dream job, but yes, your CMG is skimming off you like crazy. But even if our payor mix and contracts are a little better than those of others...you should still be making an absolute killing seeing 2.5-3 per hour. That's a ton of RVUs/revenue.

We've talked about dropping coverage to see more pph, but most of the group is just fine with our pace/income as is. Plus, it's tough to increase coverage in lower volume shops. You can't add half a doc, you can either add a full doc or do without. Going from 1 doc to 2 or 2 docs to 3 is huge compared to going from 5 to 6.

 

[The White Coat Investor]

...if you can keep that contract the rest of your life.

Thankfully just got a 5 year renewal, which should get me to financial independence! If the contract is lost at that point I'll have tons of options.

 

[emergentmd]

Thankfully just got a 5 year renewal, which should get me to financial independence! If the contract is lost at that point I'll have tons of options.

5 Yr renewal means nothing. Check the contract, I am sure there is a 90 day clause.

 

[The White Coat Investor]

5 Yr renewal means nothing. Check the contract, I am sure there is a 90 day clause.

Of course, just as there has been for 25 years through three hospital corporations. No guarantees in life.