Efficiency in Real World Psychiatry

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Yes, but it will be documented in ASSESSMENT section that a drug was used off-label. It also serves as a reminder to me to do so.




Trust me, my note would be shorter but the Army is so focused on making sure the paperwork is correct...even if that means less time with the patient.


What you're experiencing is no different than your AD counterparts and certainly no different than any other Government service, including the VA. The Government doesn't care about quality, only numbers.

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Like this blurb I see in primary care notes. I guess this one will be around for years.

"In the previous 21 days, the individual HAS NOT resided or traveled to one or more of the following countries in West Africa: Liberia, Sierra Leone, Guinea, Nigeria, or in a region where Ebola Virus Disease (EVD) transmission is active.
The patient HAS NOT HAD contact or interaction with someone who might have Ebola, or the body fluids, surroundings or remains of an Ebola patient during the past 21 days.
The patient HAS NOT HAD a fever OR nausea/vomiting, diarrhea, abdominal/stomach pain, joint and muscle ache, severe headache, new skin rash or unexplained bruising or bleeding in the past 21 days."
 
You pretty much have to learn that our treatments work better on symptoms rather than DSM diagnoses, and the sooner you learn to gather histories in a way that efficiently collects symptoms in a way that helps you learn which treatments will help the patient, the more "efficiently" you'll be able to work. At the end of the day... how critical is it to parse out whether the patient has Panic Disorder, GAD, or Anxiety NOS? Do you really need to figure out whether the patient has 4 or 5 out of 9 criteria for MDD or Borderline PD? And if you aren't going to do anything to address a disorder (ADHD, Dissociative Disorders, any cognitive deficits you see on exam, etc), there's no point in asking about it. There are obvious exceptions to this (bipolar vs unipolar depression, etc), but by the time you finish residency, you know when you need to spend time figuring out the right treatments for the right disorder and when you can just give a psychotic patient Risperdal or Zyprexa.

Otherwise, there are a lot of little things that will enhance or impair your efficiency. These include being proficient at redirecting patients. If you're inpatient, you need to be good at scheduling and structuring your workday so it's not disrupted by other commitments and by the myriad other distractors (patients and other staff) that will slow you down.

So are you saying you're loose with DSM-5 diagnosis? For example, if you see a patient with history of trauma who have nightmares, are hyperviligant, and easily startled, and no other PTSD criteria do you slap PTSD on them?
 
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So are you saying you're loose with DSM-5 diagnosis? For example, if you see a patient with history of trauma who have nightmares, are hyperviligant, and easily startled, and no other PTSD criteria do you slap PTSD on them?
PTSD in DSM-5 literally has 20 symptoms you may need to check for in re-experiencing, hyperarousal, numbing/cognition, and avoidance before you can make the diagnosis. Do you go through all of them? I'll admit that I don't. It just takes too much time. I don't have half of them memorized either (I just took boards with all the DSM-IV criteria). But no, I don't slap PTSD on them. Doesn't mean those symptoms don't affect treatment.
 
PTSD in DSM-5 literally has 20 symptoms you may need to check for in re-experiencing, hyperarousal, numbing/cognition, and avoidance before you can make the diagnosis. Do you go through all of them? I'll admit that I don't. It just takes too much time. I don't have half of them memorized either (I just took boards with all the DSM-IV criteria). But no, I don't slap PTSD on them. Doesn't mean those symptoms don't affect treatment.

I just give them the PCL and dictate from that.
 
So are you saying you're loose with DSM-5 diagnosis? For example, if you see a patient with history of trauma who have nightmares, are hyperviligant, and easily startled, and no other PTSD criteria do you slap PTSD on them?
In the military as there can be service connection and money involved, I understand why the paperwork and dx is extremely stringent.
 
I have a rather extensive template in EPIC (not in the real world yet though), which solves the checkbox != narrative problem. Essentially it says something like:

"He/She (epic knows which one) reports/denies (I choose) the following symptoms of depression:" Then there's a drop down box that lets me click a fairly detailed version of SIGECAPS. For example, the sleep choices include: initially insomnia, midnight insomnia, terminal insomnia, hypersomnia, etc and EPIC writes this out like a sentence and puts the appropriate "and" between the last 2 choices, so when it's done it reads like:

"He reports the following symptoms of depression: initial insomnia, hopelessness, helplessness, low energy, and decreased appetite. He denies suicidal ideation at this time."

I can right click and edit this (like add some details in parentheses after hopelessness.) or I can just put things at the end of it. So if I need to add anything to make it more clear I do.

The mental status exam is similar and I've gone to rather absurd lengths to build a set of "checkboxes" that give me a wide range of MSE's. Each one also has a wild card so I can free type out my MSE if a choice isn't there.

The risk assessment is in paragraph form and has checkboxes for reports/denies various risk factors (presence of guns at home), then their chronic and acute risk is documented as low, high, elevated, or whatever descriptor I want.

It's not ideal, but I can usually get an intake note done in less than 10 minutes. Much less if they're not complicated. I dictate at my moonlighting gig and am FAR slower at it and it's not as good for my non-linear brain. With this, if I forget something I can easily go back and add it before I sign the note. I'm always dictating things like, "can you go back up to the HPI and add this..." Not a problem in EMR land.

Can I contract with EPIC to get this EMR? Has anyone tried any other EMRs like AdvancedMD, Kareo, NeuMD, Therapy Notes? Pros and cons with regards to efficiency, billing and user-friendliness for a psychiatrist will be appreciated.
 
I am the fastest pgy-2 "scribe" in my residency and my notes have been praised as "efficient, but cover all the important points" by 85% of attendings I work with.

The remainder 15% hate my guts and threaten to fail me because I don't write Shakespearean novels singing the praises of JACO. In the end, they are nothing but empty threats.

I always try to teach the interns to write less ("if each word cost you a $1 to write in your formulation, what would be the most important things to document?"). Usually we'll both start a patient encounter, and if I'm done with the interview, orders, notes, and collateral, and the intern is still typing his HPI, I'll say "psst you're writing too much :p"
 
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I am the fastest pgy-2 "scribe" in my residency and my notes have been praised as "efficient, but cover all the important points" by 85% of attendings I work with.

The remainder 15% hate my guts and threaten to fail me because I don't write Shakespearean novels singing the praises of JACO. In the end, they are nothing but empty threats.
quite apart from there being no such a thing as a Shakespearean novel, writing efficiently and writing lyrically are not mutually exclusive. bonus points if you can write your assessment in iambic pentameter.
 
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I am the fastest pgy-2 "scribe" in my residency and my notes have been praised as "efficient, but cover all the important points" by 85% of attendings I work with.

The remainder 15% hate my guts and threaten to fail me because I don't write Shakespearean novels singing the praises of JACO. In the end, they are nothing but empty threats.

I always try to teach the interns to write less ("if each word cost you a $1 to write in your formulation, what would be the most important things to document?"). Usually we'll both start a patient encounter, and if I'm done with the interview, orders, notes, and collateral, and the intern is still typing his HPI, I'll say "psst you're writing too much :p"

The longer I'm in training the shorter my notes are. I guess it's no surprise that I enjoy the fast pace of C&L and ED rotations compared to our Specialty consult clinics where an evaluation may take 3 hours...
 
The longer I'm in training the shorter my notes are. I guess it's no surprise that I enjoy the fast pace of C&L and ED rotations compared to our Specialty consult clinics where an evaluation may take 3 hours...
From my experience it's less about the service but more the style of attendings that you work with... for example one of my CL attendings wrote the longest notes I've ever seen and just walls of texts in recommendations (which no doubt goes completely unread...), whereas I've seen "niche experts" write things like "A/P depression - cont meds"
 
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