Efficiency in Real World Psychiatry

[peppy]

All through residency, I've heard vague comments about how "you learn to be more efficient" once you are in the real world of private practice, non-teaching hospitals, etc. but none of my academic attendings ever give concrete advice about how to actually do it. Here at least, it is basically expected you will do a five page long note on academic consults right up until you graduate. Then you're supposed to just know how to condense the important stuff down.

Do any of you experienced docs have any tips on how to be efficient without becoming sloppy or careless?

I feel like some of the bad psychiatry practice we see out there happens because people aren't given guidance on how to be efficient but still practice good medicine. I bet some people end up cutting corners on things they really shouldn't just trying to figure out how to manage patient loads that residency didn't prepare them for.

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[MacDonaldTriad]

All through residency, I've heard vague comments about how "you learn to be more efficient" once you are in the real world of private practice, non-teaching hospitals, etc. but none of my academic attendings ever give concrete advice about how to actually do it.

At least they didn't confabulate because many of them wouldn't know anything about the "real world".

 

[Shikima]

All through residency, I've heard vague comments about how "you learn to be more efficient" once you are in the real world of private practice, non-teaching hospitals, etc. but none of my academic attendings ever give concrete advice about how to actually do it. Here at least, it is basically expected you will do a five page long note on academic consults right up until you graduate. Then you're supposed to just know how to condense the important stuff down.

Do any of you experienced docs have any tips on how to be efficient without becoming sloppy or careless?

I feel like some of the bad psychiatry practice we see out there happens because people aren't given guidance on how to be efficient but still practice good medicine. I bet some people end up cutting corners on things they really shouldn't just trying to figure out how to manage patient loads that residency didn't prepare them for.

It comes down to environment familiarity. With practice and repetition, your efficiency will grow then the system will change, efficiency will go down but then pick back up as you adapt to the new system.

 

[F0nzie]

When you are learning medicine you do the full review of systems. When you are comfortable with medicine you do a focused review of systems. When you are learning psychiatry you do a full psychiatric assessment. When you are comfortable with psychiatry you do a focused psychiatric assessment.

You need to learn to prioritize based on the presentation and the practice setting. This will come with experience. Although I will say there are many experienced psychiatrists that are obsessive about asking every possible question that they can't possibly address. Basically mental masturbation that does not help the patient. These psychiatrists tend to not carry their weight around the clinic and you will dread working with them.

 

[F0nzie]

Whenever I see a 5 page intake on a straight forward case written by another psychiatrist the first thing I do is X out of the note and assume whoever wrote that note is sicker than the patient.

 

[Jester25]

When you are learning medicine you do the full review of systems. When you are comfortable with medicine you do a focused review of systems. When you are learning psychiatry you do a full psychiatric assessment. When you are comfortable with psychiatry you do a focused psychiatric assessment.

You need to learn to prioritize based on the presentation and the practice setting. This will come with experience. Although I will say there are many experienced psychiatrists that are obsessive about asking every possible question that they can't possibly address. Basically mental masturbation that does not help the patient. These psychiatrists tend to not carry their weight around the clinic and you will dread working with them.

While I agree with a vast majority of your posts, I somewhat disagree with this one. I think this is how patients go years without having a diagnosis such as social anxiety or bulimia picked up. People will always focus on the primary dx such as depression or GAD. I always screen all new patients to me on entire psych ROS. If they are negative, it ends up taking up 5 minutes longer. If one or more of them are positive that other clinicians did not pick up, then you are getting a much better picture of their presentation and can treat accordingly. When I say I do an entire psych ROS, I do it focused. If my clinical suspicion for bipolar disorder is low, I will ask 1-2 screening questions rather than go down the entire DIG FAST/ take a longer longitudinal history.

 

[cookymonster]

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.

 

[Jester25]

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.

While its's true that an SSRI is going to address multiple disorders, the value in knowing them is allows you to appropriately refer out ERP vs. CBT vs. HRT vs. DBT vs FBT etc...

Also, why wouldn't you address things like ADHD and cognitive disorders if they are positive on exam?

 

[milesed]

What in the world comprises a 5 pg note?

Look at the parts of visit requirements for new evals and return visit appointments and go from there- 99201-99205 and 99212-99215. Most of the info needed for these notes in being gathered already and you just need to organize it in the way insurance can recognize that yo are fulfilling the requirements for each level of care you bill for. For in depth explanations look at these videos-

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

 

[vistaril]

All through residency, I've heard vague comments about how "you learn to be more efficient" once you are in the real world of private practice, non-teaching hospitals, etc. but none of my academic attendings ever give concrete advice about how to actually do it. Here at least, it is basically expected you will do a five page long note on academic consults right up until you graduate. Then you're supposed to just know how to condense the important stuff down.

Do any of you experienced docs have any tips on how to be efficient without becoming sloppy or careless?

I feel like some of the bad psychiatry practice we see out there happens because people aren't given guidance on how to be efficient but still practice good medicine. I bet some people end up cutting corners on things they really shouldn't just trying to figure out how to manage patient loads that residency didn't prepare them for.

this is an excellent question. The obvious answer is to get some out of residency experience towards the end of your residency. I worked a lot in a community mental health type center, where you either were efficient or you got fired. That will teach you how to be efficient.

 

[thepoopologist]

The shortest note I ever saw as a medical student on consult psychiatry was when I witnessed my attending write the axes and 1 line of recommendations. Nothing else. He was the only psychiatrist in the hospital. The second shortest notes were weekend coverage notes written by a well established attending in my residency who otherwise documented comprehensively during the weekday.

 

[cookymonster]

While its's true that an SSRI is going to address multiple disorders, the value in knowing them is allows you to appropriately refer out ERP vs. CBT vs. HRT vs. DBT vs FBT etc...

Also, why wouldn't you address things like ADHD and cognitive disorders if they are positive on exam?

Your first comment is true, but the lack of access to skilled providers (and in many cases, the limits of a patient's ability to pay for them) for many of these modalities limits the utility of teasing the fine points out.

As for ADHD, it's usually not a good diagnosis to make based on history alone, especially since some patients have the DSM criteria memorized. If all you need to do is confirm they've had some previous testing, or if it helps you decide between Wellbutrin and SSRI, that's one thing. Otherwise, I'm not going to try to deal with it on an intake.

I was also mentioning cognitive deficits on exam, rather than cognitive disorders. I used to do serial sevens, 3-item recall, proverb interpretation, the last five presidents, clock-drawing, etc. Over half of my patients cannot get 3/3 items after 5 minutes, over 90 percent fail serial sevens, and in eight months as an attending, I don't think I've seen a 10/10 clock yet. I don't work on a geriatric unit and have very few patients with dementia. They perform horrendously because they're acutely ill, have been awake in the emergency room most of the previous evening, have average-low IQs and education levels, and aren't giving their best effort. If you get more concerning history of cognitive decline, sure, address that, but the only way I'm going to address deficits I discover from screening acutely ill psychiatric populations is by treating their underlying illness. So I stopped screening and saved five minutes on my initial evals.

 

[Jester25]

Your first comment is true, but the lack of access to skilled providers (and in many cases, the limits of a patient's ability to pay for them) for many of these modalities limits the utility of teasing the fine points out.

As for ADHD, it's usually not a good diagnosis to make based on history alone, especially since some patients have the DSM criteria memorized. If all you need to do is confirm they've had some previous testing, or if it helps you decide between Wellbutrin and SSRI, that's one thing. Otherwise, I'm not going to try to deal with it on an intake.

I was also mentioning cognitive deficits on exam, rather than cognitive disorders. I used to do serial sevens, 3-item recall, proverb interpretation, the last five presidents, clock-drawing, etc. Over half of my patients cannot get 3/3 items after 5 minutes, over 90 percent fail serial sevens, and in eight months as an attending, I don't think I've seen a 10/10 clock yet. I don't work on a geriatric unit and have very few patients with dementia. They perform horrendously because they're acutely ill, have been awake in the emergency room most of the previous evening, have average-low IQs and education levels, and aren't giving their best effort. If you get more concerning history of cognitive decline, sure, address that, but the only way I'm going to address deficits I discover from screening acutely ill psychiatric populations is by treating their underlying illness. So I stopped screening and saved five minutes on my initial evals.

All that makes sense.


I am a little spoiled in that my academic center has access to all sorts of therapy modalities and I'm child trained so ADHD wouldn't be a big deal, but I agree, with just my adult training, I would have had a hard time treating ADHD.

 

[doctorpilgrim]

Some psychiatrists are efficient to see 4 patients per hour. I know this can be done and many of them are competent psychiatrists doing a good job. One of my teachers did that but with no emr in private practice. I am curious to know what efficencies and documentation strategies are used by others on this forum if they do that. I have never been able to get beyond 2 patients an hour, if I do it faster, I spend 2 hours documenting in the emr and am completely worn out. Do people see the patients every month and then have a dedicated therapist also see them. Do any of you do psycho pharmacology groups. If yes how are they reimbursed or are done. Any input will be appreciated.

 

[DD214_DOC]

There is an attending at my current location who works 12-15 hours per day due to obsessiveness and inefficiency. His/her intakes are 2-3 hours long and rarely are finished in a single session. S/He creates more work for everyone around him/her and crushes morale. People like this should be fired.

A focused exam does not mean you don't bother screening. It means you screen and narrow your in-depth questioning to things that are useful. Learn the major defining symptoms for the different diagnoses; the one or two things that MUST be present for the condition to exist. Ask those first. If they're negative, then don't bother asking about the other things.

With anything, the symptoms must cause impairment or distress. If someone says they feel anxious about speaking in public, but this experience doesn't negatively impact them in some way, move on.

Agree 100% on symptom-focused evaluation and intervention. Diagnostic labels are worthless, and the answers you're getting to questions are also not likely that accurate anyway, thus making your labels inaccurate. Use common sense when deciding on a treatment.

 

[NontradCA]

Whenever I see a 5 page intake on a straight forward case written by another psychiatrist the first thing I do is X out of the note and assume whoever wrote that note is sicker than the patient.

Thank you.

 

[slappy]

All through residency, I've heard vague comments about how "you learn to be more efficient" once you are in the real world of private practice, non-teaching hospitals, etc.

No, you need to learn to be efficient while in residency.

but none of my academic attendings ever give concrete advice about how to actually do it.

Seriously? How hard is this? Just keep shortening your notes and streamlining your thought process until you're able to do a fairly comprehensive chart review, intake interview and the note within an hour, without missing any of the important points.

Here at least, it is basically expected you will do a five page long note on academic consults right up until you graduate.

That does not sound right to me. Trust me, no one, I repeat, no one, reads your four-page-long HPI. You're a doctor, and you're paid to think - not to be a scribe. So, focus on the assessment (and plan). Forget about the rest. No one cares.

 

[heyjack70]

There is an attending at my current location who works 12-15 hours per day due to obsessiveness and inefficiency. His/her intakes are 2-3 hours long and rarely are finished in a single session. S/He creates more work for everyone around him/her and crushes morale. People like this should be fired.

A focused exam does not mean you don't bother screening. It means you screen and narrow your in-depth questioning to things that are useful. Learn the major defining symptoms for the different diagnoses; the one or two things that MUST be present for the condition to exist. Ask those first. If they're negative, then don't bother asking about the other things.

With anything, the symptoms must cause impairment or distress. If someone says they feel anxious about speaking in public, but this experience doesn't negatively impact them in some way, move on.

Agree 100% on symptom-focused evaluation and intervention. Diagnostic labels are worthless, and the answers you're getting to questions are also not likely that accurate anyway, thus making your labels inaccurate. Use common sense when deciding on a treatment.

Sounds like a rough OCPD existence. How does this person create more work for others? I certainly hope they're not in a leadership roll with any influence over clinic functioning.

 

[Doctor Bagel]

Sounds like a rough OCPD existence. How does this person create more work for others? I certainly hope they're not in a leadership roll with any influence over clinic functioning.

People like this often create more work for their trainees. Hard to imagine how they create more work for their colleagues, though. Speaking of painful (and screening), I have a friend who was working with an attending who insisted on reading every single symptom of every single category of the ROS to patients in their initial screen.

 

[doctorpilgrim]

With an emr, ordering electronic scripts, entering electronic coding, entering diagnosis, getting electronic consent for medication, typing in assessment and plan, capturing 99213 elements, reviewing the labs, quick review of medical issues, it keeps adding upto 30 minutes for follow up visit. This is for a simple visit, if there is a crisis going on then that adds further time. I keep thinking if people who are efficient are using a particular emr. In the VA or non psychiatric emr I find it difficult to see more patients.

 

[Zenman1]

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.

The psychologists around here, and a few therapists, will check off every criteria for a diagnosis in their notes. I should just cut my interviewing time down to the bare essentials and then let them do all the diagnositic fine-tuning.

 

[doctorpilgrim]

What I am referring to is not the psychiatric knowledge and expertise. Most psychiatrists like me have sufficient fund of knowledge and experience to diagnose and formulate a treatment plan relatively quickly. But those of us who work with electronic medical records, the emr dictates our workflow. So we have to check all boxes like put in the diagnosis as chief complaint, as diagnosis itself, for medications, then again for billing. What I was asking was the experience of others with psychiatry specific emr in private practice vs working in a big organization with rigid work flow, How that impacts their efficiency.

 

[milesed]

Specifics for how I see a new patient in 30 minutes-

1. We have an EMR and all patients have seen a therapist at least once so most relevant info is there. I just copy and paste it into my note as a starting point. I also have a partly completed MSE saved in a word doc that is copied, pasted and then modified as we go.

2. All hospital d/c info is scanned into emr, so it is reviewed and typed into my note.

3. Rating scales (if needed) are already completed, scaled and in the emr for me to review if applies.

4. Patients are given a 1 page sheet with complete review of systems they are to circle issues they are having that are new.
ALL of this is done before I ever sit down with a patient.

5. I type as I talk to them. I type, stop and talk, type some more. This part is not ideal. Others working here do notes after they finish with a patient, but I want it all down to avoid forgetting or leaving out anything. I'm also able to print them a copy of the note if needed right then.


I bring them back, measure ht, wt as I'm telling them that we will review all info I have already seen. I measure BP, pulse then we talk.

I go sort of in reverse order of the traditional CC, HPI, etc. as I review Family, Social, medical and past psyc hx. that I already have entered into the note as I gather MUCH more detail ( doses of meds, length of tx, family response to their treatments, and even review a family member's hx of sxs if they claim to have a psychotic or mood disorder- MANY are misdiagnosed as bipolar who are depressed with anxiety, borderline PD or drug users).

Then I get to CC and HPI, then A/P. I already entered lots of the hpi info and it is reviewed, modified and added to.
I spend most of my time on education on dx, risks of treatment options and what they should start covering in therapy. I sometimes start some CBT with them. Then I enter Rx into emr, write out labs orders and walk them up to get checked out. I explain when to return, how to call with problems as we walk. If they have trouble with any of this, I write out things on paper for them. I also have some of my more common instructions already typed and printed on paper to hand them.

I didn't start this way and was used to 1 hour evals and 30 minute f/u. I used every minute of each doing what I now do in half then time. You live and learn. If you have never read any Malcolm Gladwell books, he talks about a point where people get really good at what they after around 10,000 hours of practice. You won't hit this point until a few years after residency.
It will come with time.

 

[F0nzie]

Specifics for how I see a new patient in 30 minutes-

1. We have an EMR and all patients have seen a therapist at least once so most relevant info is there. I just copy and paste it into my note as a starting point. I also have a partly completed MSE saved in a word doc that is copied, pasted and then modified as we go.

2. All hospital d/c info is scanned into emr, so it is reviewed and typed into my note.

3. Rating scales (if needed) are already completed, scaled and in the emr for me to review if applies.

4. Patients are given a 1 page sheet with complete review of systems they are to circle issues they are having that are new.
ALL of this is done before I ever sit down with a patient.

5. I type as I talk to them. I type, stop and talk, type some more. This part is not ideal. Others working here do notes after they finish with a patient, but I want it all down to avoid forgetting or leaving out anything. I'm also able to print them a copy of the note if needed right then.


I bring them back, measure ht, wt as I'm telling them that we will review all info I have already seen. I measure BP, pulse then we talk.

I go sort of in reverse order of the traditional CC, HPI, etc. as I review Family, Social, medical and past psyc hx. that I already have entered into the note as I gather MUCH more detail ( doses of meds, length of tx, family response to their treatments, and even review a family member's hx of sxs if they claim to have a psychotic or mood disorder- MANY are misdiagnosed as bipolar who are depressed with anxiety, borderline PD or drug users).

Then I get to CC and HPI, then A/P. I already entered lots of the hpi info and it is reviewed, modified and added to.
I spend most of my time on education on dx, risks of treatment options and what they should start covering in therapy. I sometimes start some CBT with them. Then I enter Rx into emr, write out labs orders and walk them up to get checked out. I explain when to return, how to call with problems as we walk. If they have trouble with any of this, I write out things on paper for them. I also have some of my more common instructions already typed and printed on paper to hand them.

I didn't start this way and was used to 1 hour evals and 30 minute f/u. I used every minute of each doing what I now do in half then time. You live and learn. If you have never read any Malcolm Gladwell books, he talks about a point where people get really good at what they after around 10,000 hours of practice. You won't hit this point until a few years after residency.
It will come with time.

Fellowship in meaningful use 🙂

 

[peppy]

Whenever I see a 5 page intake on a straight forward case written by another psychiatrist the first thing I do is X out of the note and assume whoever wrote that note is sicker than the patient.

I totally understand. 🙂 I was thinking this was an "academia" thing, but it may be more of my program's culture. For example, in one of the community clinics I work at, I have to fill out a lengthy intake form that is meant to screen for all manner of various social ills in addition to psychiatric symptoms - and yes, I have been chastised for not filling out parts of the form because (for example) I didn't feel that delving into the patient's childhood and family background would make a difference in a particular case. Unless you get a patient who is very guarded and doesn't want to talk (which is actually kind of a blessing in this situation), it literally takes an hour just to go through every question and fill out the form, and then after staffing the case with my supervisor it becomes a 90 minute appointment.

It really helps to get the opinions of experienced docs about high yield techniques, so that those of us who are new can learn to be quick *without* falling into bad habits. I have read some private practice psychiatrist notes that were so brief that they really weren't helpful or informative...and might potentially be a legal liability if that person was ever sued for malpractice.

 

[Shikima]

Meaningful use be damned. The Government has no need to collect data.

 

[carlsbad]

Practice and more practice. Continual process improvement and evaluation. Certainly it gets easier the longer you do it. Having a good EMR and being a good typist helps a lot. For new patients I create a template that is at least partially completed before I see them. For follow-ups, I find it helpful to not type anything until about half-way through the appointment, which helps me avoid writing too much and staying more succinct.

 

[heyjack70]

I've said it once and I'll say it a thousand times: learn to dictate your notes in residency! I can dictate a 3 page admit note in 5 minutes. To type such a detailed note would probably take 25 minutes at least. If your hospital has an EMR that most people type into, you should ask if there is any way to dictate. The older attendings will probably know if it is possible because most of them can't type very well and still dictate. It is a little rough initially, but even initially it's faster than typing.

 

[Shikima]

I've said it once and I'll say it a thousand times: learn to dictate your notes in residency! I can dictate a 3 page admit note in 5 minutes. To type such a detailed note would probably take 25 minutes at least. If your hospital has an EMR that most people type into, you should ask if there is any way to dictate. The older attendings will probably know if it is possible because most of them can't type very well and still dictate. It is a little rough initially, but even initially it's faster than typing.

With meaningful use going to stage 2 and then stage 3, this isn't an option in the future.

 

[Bartelby]

I've said it once and I'll say it a thousand times: learn to dictate your notes in residency! I can dictate a 3 page admit note in 5 minutes. To type such a detailed note would probably take 25 minutes at least. If your hospital has an EMR that most people type into, you should ask if there is any way to dictate. The older attendings will probably know if it is possible because most of them can't type very well and still dictate. It is a little rough initially, but even initially it's faster than typing.

With a real dictation service or something like Dragon Dictation? I am very interested in this but haven't found Dragon to be that much faster. Any tips for getting started?

 

[Shikima]

With a real dictation service or something like Dragon Dictation? I am very interested in this but haven't found Dragon to be that much faster. Any tips for getting started?

Dragon can be useful in setting up templates and pre-population of data prior to the start of the appointment. Cannot be used during the session. Again, in the future, the difficulty will be getting all the "data" into the note and have the clinical summary printed out for the Pt at the end per MU1/2/3 criterion.

 

[heyjack70]

That meaningful use but sucks. Straight up. I'm talking about true dictation with a transcriptionist. It's the best.

 

[Shikima]

And it's going away slowly... like the Dodo and the Tazmania Devil.

 

[Therapist4Chnge]

1. Address the referral question, and make sure it is specific. "Assess and treat" is not a real referral question. If needed, go back and clarify exactly what the referrer wants.

2. You are being tapped for your expertise, so that is where your focus should be, assuming the case isn't completely cold off the street w. no documentation. It is okay to say, "refer to SW note on XX.XX.XX for more social/family background." Focus on what is needed, not on writing the most perfect note ever.

With a real dictation service or something like Dragon Dictation? I am very interested in this but haven't found Dragon to be that much faster. Any tips for getting started?

1. Invest in a high-quality mic (there are plenty of reviews out there).

2. Have a solid template to use as a reference in front of you, and after a dozen notes or so you should be able to work out the kinks. You'll probably need a few different templates, depending on the type of consult/eval.

 

[milesed]

I tried Dragon and it was taking more time to correct all of the mistakes it made than it took to type the note myself. Yes, I "trained" it many, many times as I can't type worth anything and was highly motivated to get it to work.

 

[VMSmith]

It helps your efficiency when you know what you want to get out of your face-to-face time with the patient, as well as finding out at the beginning what the patient wants to get out of it (that way you don't get surprised at the end with paperwork requests). Then you focus on spending your time together gathering enough info to answer your question and their question(s), and when you decide on a treatment just make sure you spend some time ensuring that what you prescribe isn't going to be harmful in some way that you could've anticipated if you asked.

Then when you are writing notes, focus on writing things that justify your decision, some time documenting what you discussed in terms of safety and informed consent re: meds, and meet the criteria for whatever level of service you plan on billing at.

A lot of what you're required to document during residency is for educational purposes, or to demonstrate your understanding of issues that aren't necessarily directly related to what you are doing with the patient, or depend on you having the extra time to delve into those areas.

 

[VMSmith]

And if there is any way for you to collect the medication history from the patient (either from the EMR, or having the patient fill it out before seeing you) including doses, duration, and beneficial as well as adverse effects, that helps TREMENDOUSLY in terms of letting you make decisions about next steps without having to spend several minutes going through each med one by one.

 

[Therapist4Chnge]

I tried Dragon and it was taking more time to correct all of the mistakes it made than it took to type the note myself. Yes, I "trained" it many, many times as I can't type worth anything and was highly motivated to get it to work.

Did you use a high-quality mic? Many people don't want to drop $200-$300 on a mic, but it really does make a difference.

I actually don't dictate anymore (the type of paperwork I do is easier done typing), though basically every high-volume user of Dragon/similar will recommend a professional mic and not some junk you pick up at Staples. I do know it can struggle w. certain accents, but it's been a number of years since I've really looked at the software so YMMV.

 

[SeniorWrangler]

With a good template and something like Dragon Dictate, you can speed up your psychiatric intake tremendously. In my experience, nobody will ever read a 5 page assessment and nobody will pay you any more... In my opinion, there is zero added value in all the added verbiage in most teaching hospital notes. And using the template guarantees that you will be able to bill properly for it.

I try to leave a little more room for psychiatric formulation in my assessment at the end of the note, but the rest is extremely focused and detail oriented, more like an internal medicine note.

 

[Bartelby]

I have started using a better microphone (and installed dragon on a faster computer) and the accuracy has increased quite a bit. I find I am able to dictate at a normal speed and then edit out all the mistakes in just a few minutes, so I think I have gotten some time savings for intakes overall (although for shorter progress notes I still find typing easier). It is taking some getting used to because it feels much easier to plan out as I write compared to as I speak, though I imagine this just comes down to practice.

For those of you using templates, do you mean it has:
Chief complaint:

HPI:

PPH:
-Diagnoses:
-Hospitalizations:
etc...

or something else? The generic templates/headers seem to be pretty standard, just wondering if there is something I'm missing.

 

[Zenman1]

With a good template and something like Dragon Dictate, you can speed up your psychiatric intake tremendously. In my experience, nobody will ever read a 5 page assessment and nobody will pay you any more... In my opinion, there is zero added value in all the added verbiage in most teaching hospital notes. And using the template guarantees that you will be able to bill properly for it.

I try to leave a little more room for psychiatric formulation in my assessment at the end of the note, but the rest is extremely focused and detail oriented, more like an internal medicine note.

How about a sample? I'll provide one of mine when I go back in to work which will be Sat as I have two intakes to dictate.

 

[PistolPete]

That would be great to see a sample, Zenman1. Nice to see so many practical suggestions for how to make a real-world private practice run smoothly and efficiently.

 

[Zenman1]

That would be great to see a sample, Zenman1. Nice to see so many practical suggestions for how to make a real-world private practice run smoothly and efficiently.

I'm not in private practice but in the very real-world of the Army, as a civilian. However, I'm very interested in efficiency but frankly, after being required to document my work hours on two different payroll systems (2nd one started this week), my government BS meter has redlined.

 

[Zenman1]

This is the intake template that I use and that transcription has at my place. I use the same to jot down notes when interviewing a patient. It's kinda jacked after loading it here but you can see it's pretty standard for most part.

NEW PATIENT INTAKE

E&M NOTE: Time Start: Time End:

IDENTIFYING DATA:

CHIEF COMPLAINT:

REFERRED BY:

HISTORY OF PRESENT ILLNESS:

PSYCHIATRIC HISTORY:

MEDICAL HISTORY:

SUBSTANCE HISTORY:

ALLERGIES:

CURRENT MEDS:

SUPPLEMENTS:

DIET:

CAM THERAPIES:

FAMILY MEDICAL HISTORY:

FAMILY PSYCHIATRIC HISTORY:

SOCIAL HISTORY:

REVIEW OF BHDP:

REVIEW OF SYSTEMS: []Const []Eyes []ENT/Mouth []CV []Resp []GI []GU []Skin/Breasts []Neuro

[]Endocrine []Hem/Lymph []Allergy/Immune []Musculoskeletal []OB/GYN

*Note: All reviewed. Findings:


VITAL SIGNS:

BP:

P:

WT:

BMI:

MUSCULOSKELETAL: ()Strength Normal/=Bilaterally ()Normal Gait/Station ()Other:

MENTAL STATUS EXAMINATION:

Appearance: (x)WDWN ()Well Groomed ()Injuries/Pain ()Assist Devices ()Other:

Behavior: (x)Cooperative ()Guarded ()Hostile ()Other:

Speech/Language: (x)Normal ()Delayed ()Excessive ()Paucity ()Pressured ()Other:

Mood: Affect: (x)Normal Range ()Tearful ()Labile ()Constricted ()Flat ()Other:

Thought Process: (x)LLGD ()Disorganized ()Tangential ()Circumstantial ()Other:

Thought Content: (x)Unremarkable ()SI ()HI ()AH ()VH ()Delusions ()Mania ()O/C ()Other:

Orientation: (x)Time ()Place ()Person ()Situation ()Other:

Memory: (x)Intact Recent (x)Intact Remote ()Other:

Attention/Concentration: (x)Intact ()Distractible/Inattentive ()Other:

Judgment/Insight: (x)Good ()Fair ()Poor ()Other:

Fund of Knowledge: (x)Education/Age Appropriate ()Other:

Impulse Control🙁x)Appropriate ()Poor due to:


RISK ASSESSMENT:

Risk for: ()None ()Suicide ()Homicide ()AWOL *Note:

Protective Factors: ()Family ()Career ()Pet ()Religion ()Resiliency *Other:

Safety Plan: ()Walk-in ()Command ()Chaplain ()ED *Other:

Patient demonstrates enough practical judgment and impulse control to believe that they can self-monitor and access crisis care if needed.

ASSESSMENT/IMPRESSION:


Axis I:

Axis II:

Axis III:


PLAN:

1. Meds:

2. Labs:

3. Next Visit:

4. Consults/Referrals:

5. Therapist:

6. Profile:

7. Polypharmacy:

8. Other:

TREATMENT GOALS/TIME FRAME:
(x)To achieve highest possible remission of symptoms considering all factors involved. (x)To provide optimal level of individualized care to patient. (x)To continually reassess and make needed revisions in care of patient. (x)To make appropriate referrals when indicated. (x)To accomplish highest possible remission in 6-12 months.

EDUCATION:
(x)Key risks & benefits of medication regimen have been discussed & patient has verbalized understanding and consents to prescribed medications. (x)Patient has been informed how to obtain refills, to call in if no refills remain, and to use meds only as prescribed. (x)Meds will be used for FDA approved conditions, or if used off-label, rationale for their use will be documented. (x)Med education form for the prescribed drug(s) provided either by pharmacy or prescriber. (x)The patient has been educated on realistic expectations from treatment & necessity for internal drive to recover as well as personal responsibility for compliance. (x)The patient verbalizes understanding & agreement with the overall treatment goals and plan.

 

[heyjack70]

This is the intake template that I use and that transcription has at my place. I use the same to jot down notes when interviewing a patient. It's kinda jacked after loading it here but you can see it's pretty standard for most part.

NEW PATIENT INTAKE

E&M NOTE: Time Start: Time End:

IDENTIFYING DATA:

CHIEF COMPLAINT:

REFERRED BY:

HISTORY OF PRESENT ILLNESS:

PSYCHIATRIC HISTORY:

MEDICAL HISTORY:

SUBSTANCE HISTORY:

ALLERGIES:

CURRENT MEDS:

SUPPLEMENTS:

DIET:

CAM THERAPIES:

FAMILY MEDICAL HISTORY:

FAMILY PSYCHIATRIC HISTORY:

SOCIAL HISTORY:

REVIEW OF BHDP:

REVIEW OF SYSTEMS: []Const []Eyes []ENT/Mouth []CV []Resp []GI []GU []Skin/Breasts []Neuro

[]Endocrine []Hem/Lymph []Allergy/Immune []Musculoskeletal []OB/GYN

*Note: All reviewed. Findings:


VITAL SIGNS:

BP:

P:

WT:

BMI:

MUSCULOSKELETAL: ()Strength Normal/=Bilaterally ()Normal Gait/Station ()Other:

MENTAL STATUS EXAMINATION:

Appearance: (x)WDWN ()Well Groomed ()Injuries/Pain ()Assist Devices ()Other:

Behavior: (x)Cooperative ()Guarded ()Hostile ()Other:

Speech/Language: (x)Normal ()Delayed ()Excessive ()Paucity ()Pressured ()Other:

Mood: Affect: (x)Normal Range ()Tearful ()Labile ()Constricted ()Flat ()Other:

Thought Process: (x)LLGD ()Disorganized ()Tangential ()Circumstantial ()Other:

Thought Content: (x)Unremarkable ()SI ()HI ()AH ()VH ()Delusions ()Mania ()O/C ()Other:

Orientation: (x)Time ()Place ()Person ()Situation ()Other:

Memory: (x)Intact Recent (x)Intact Remote ()Other:

Attention/Concentration: (x)Intact ()Distractible/Inattentive ()Other:

Judgment/Insight: (x)Good ()Fair ()Poor ()Other:

Fund of Knowledge: (x)Education/Age Appropriate ()Other:

Impulse Control🙁x)Appropriate ()Poor due to:


RISK ASSESSMENT:

Risk for: ()None ()Suicide ()Homicide ()AWOL *Note:

Protective Factors: ()Family ()Career ()Pet ()Religion ()Resiliency *Other:

Safety Plan: ()Walk-in ()Command ()Chaplain ()ED *Other:

Patient demonstrates enough practical judgment and impulse control to believe that they can self-monitor and access crisis care if needed.

ASSESSMENT/IMPRESSION:


Axis I:

Axis II:

Axis III:


PLAN:

1. Meds:

2. Labs:

3. Next Visit:

4. Consults/Referrals:

5. Therapist:

6. Profile:

7. Polypharmacy:

8. Other:

TREATMENT GOALS/TIME FRAME:
(x)To achieve highest possible remission of symptoms considering all factors involved. (x)To provide optimal level of individualized care to patient. (x)To continually reassess and make needed revisions in care of patient. (x)To make appropriate referrals when indicated. (x)To accomplish highest possible remission in 6-12 months.

EDUCATION:
(x)Key risks & benefits of medication regimen have been discussed & patient has verbalized understanding and consents to prescribed medications. (x)Patient has been informed how to obtain refills, to call in if no refills remain, and to use meds only as prescribed. (x)Meds will be used for FDA approved conditions, or if used off-label, rationale for their use will be documented. (x)Med education form for the prescribed drug(s) provided either by pharmacy or prescriber. (x)The patient has been educated on realistic expectations from treatment & necessity for internal drive to recover as well as personal responsibility for compliance. (x)The patient verbalizes understanding & agreement with the overall treatment goals and plan.

I've heard that these boiler plate, or check box, forms are not good if you get sued, especially the parts documenting informed consent/refusal. Has anyone heard of lawsuits where this has been an issue?

 

[Bartelby]

Thanks for posting zenman! Good question heyjack, I was actually thinking when I looked at the template that those phrases with checkboxes are something I would like to add to my own notes but that is worth considering. I imagine they are valid but would like to hear if anyone has heard more about that.

I like using checkboxes just for that run of the mill (basically) fluff that has be documented for CYA purposes. I loathe it when the mental status exam, PPH or HPI is just a series of checkboxes without almost any narrative. I have actually seen that in a number of outside hospital notes along with like a one paragraph (generally worthless) assessment at the bottom. I imagine that kind of note is where you run into a trouble when an adverse event happens and you have to prove non-negligence. The checkbox sentences at the bottom of this template seem less shady to me.

 

[digitlnoize]

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.

 

[hamstergang]

(x)Meds will be used for FDA approved conditions, or if used off-label, rationale for their use will be documented.

Thanks for sharing.

It's lines like this one, though, that bother me. It's so clear it was checked off before seeing the patient. You should document what you actually did, not list out options of what you might have done depending on which actually applies to this particular patient.

TREATMENT GOALS/TIME FRAME:
(x)To achieve highest possible remission of symptoms considering all factors involved. (x)To provide optimal level of individualized care to patient. (x)To continually reassess and make needed revisions in care of patient. (x)To make appropriate referrals when indicated. (x)To accomplish highest possible remission in 6-12 months.

This is something else I see a lot and don't understand. What's the purpose of this part, especially when included like this for everyone?

 

[Armadillos]

Thanks for sharing.

It's lines like this one, though, that bother me. It's so clear it was checked off before seeing the patient. You should document what you actually did, not list out options of what you might have done depending on which actually applies to this particular patient.


This is something else I see a lot and don't understand. What's the purpose of this part, especially when included like this for everyone?

I'm guessing a checkbox like that comes from an institutional level decision not individual providers?

 

[Zenman1]

Thanks for sharing.

It's lines like this one, though, that bother me. It's so clear it was checked off before seeing the patient. You should document what you actually did, not list out options of what you might have done depending on which actually applies to this particular patient.

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.

This is something else I see a lot and don't understand. What's the purpose of this part, especially when included like this for everyone?

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.