Free text vs click box charting

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wareagle726

wareagle726

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PGY-3 here. Worked with an attending of ours who does all charts free text using "hot texts" and macros on a blank canvas. Tried it last shift and seemed much more efficient and much less redundant. Granted, I have a passion for billing/coding so I have a pretty good grasp on what absolutely has to be in there and have a doc with macros at the ready. Just wondering yall's thoughts on this vs the corner click box mentality.
 
wareagle726 said:
PGY-3 here. Worked with an attending of ours who does all charts free text using "hot texts" and macros on a blank canvas. Tried it last shift and seemed much more efficient and much less redundant. Granted, I have a passion for billing/coding so I have a pretty good grasp on what absolutely has to be in there and have a doc with macros at the ready. Just wondering yall's thoughts on this vs the corner click box mentality.
Click to expand...

Click boxes make all charts look like crap. And if you have to go back and edit it takes even longer. I'm probably the fastest charter at my program and I free text everything via dictation. Only a small amount of macros. Watching people go through the click boxes reminds me of the people who one finger type by pecking
 
I’m torn. During my transitional year, we used Cerner with macros and click boxes. Even though we clicked, we were still required to dictate an HPI that correlated with what we clicked. Once I got everything dialed in and my macros set, it was great.

Moved on to my actual PGY-1 year institution that used MediTech and MModal. Little to no clicking and more free text. I had voice commands set up for HPI, ROS, PE, CXR and EKG interpretation, MDM, and Critical Care time. Could fly through an easy chart in a few minutes. Actually liked it better than Cerner and seemed to have better documentation productivity with it. Heck, we still had attendings that did telephone dictation.

Now, where I’ve restarted PGY-1 after the closure has Cerner, but we’re not allowed to use the PowerNotes or click boxes. I’ll have to get everything set up in Dragon and see how it turns out.
 
I built about 10 dictation templates in EPIC and share them with all the new residents when they start. They then usually edit the exam to change phrasing to their own language. We all dictate. I don't know anyone in our ED that uses the click boxes. Its terribly inefficient to do so, and the notes are utter garbage from a medical-legal standpoint.
 
@CajunMedic - would you be so kind as to tell us briefly how to set up the voice commands to fill out the boxes in MediTech? My one job site uses it, and I would love to say "Insert Level 5 ROS" and have it fill out those damn boxes.
 
I like Cerner’s clickedy click + Dragon Dictate. I click all the requisite fields and then dictate my HPI and MDM. I can crank out charts crazy fast. If it's a simple case, I don't even bother to dictate anything. I have macro's set up for the ROS and PE with occasional smart phrases. I don't even use a scribe anymore and I'm even faster than I was before... All my charts are up to date as I go and completed at the time of discharge and shortly after the time of admission. I never have uncompleted charts when I leave and I leave on time every shift with a small paragraph of dictated MDM on moderately complex cases. 2.3PPH average but other day was 3.2pph and still left on time.

I hated all the clicking in Cerner when we first started using it but now I love it. Macros, smart phrases and dictation is the perfect combination. I'm a fast typer and was slow to adopt Dragon but now I'll freely admit that I can dictate way faster than I can type.
 
Groove said:
I like Cerner’s clickedy click + Dragon Dictate. I click all the requisite fields and then dictate my HPI and MDM. I can crank out charts crazy fast. If it's a simple case, I don't even bother to dictate anything. I have macro's set up for the ROS and PE with occasional smart phrases. I don't even use a scribe anymore and I'm even faster than I was before... All my charts are up to date as I go and completed at the time of discharge and shortly after the time of admission. I never have uncompleted charts when I leave and I leave on time every shift with a small paragraph of dictated MDM on moderately complex cases. 2.3PPH average but other day was 3.2pph and still left on time.

I hated all the clicking in Cerner when we first started using it but now I love it. Macros, smart phrases and dictation is the perfect combination. I'm a fast typer and was slow to adopt Dragon but now I'll freely admit that I can dictate way faster than I can type.
Click to expand...

Do you use one of those COWs and walk around pushing it into patients rooms, or do you go back and forth between patients rooms and a desktop?

Is your general workflow see 1 patient, put in orders, dictate, see another patient and so forth...or will you see two or three patients at a time, then sit down and put in all the orders and make the charts?

I use scribes and I’m still inefficient. Prob for a variety of reasons. Statistically over the course of a year, I average 2.2 (2.18). What slows me down is 1) me... just being slow I guess. Although at the end of the day 2.2/hr isn’t that bad. 2) if I’m doing my own charts, pulling in EKGs and imaging is such a time suck. We use Cerner. Unlike labs where they are imported, I wish i could just click on a button and incorporate all imaging and EKGs. Right now it’s a copy paste thing. Imagine a trauma with a pan scan and 6 xrays. Takes FOREVER. 3) dispo instructions. I always detail mine, i try to make itemized lists. I’ve read patient compliance improves with itemized lists. But it just takes time.

I’m envious that you see as many, actually more than me and get all your charts done on time and you leave on time.

For what it’s worth...i feel I’m faster with epic than cerner. With epic...it’s one huge free text note and i use macros. And I never import imaging studies i just summarize them in my note. In epic...i type a quick HPI, I macro in a ROS, jump to the exam....put in a macro and makes edits as needed....import all labs....type my MDM. Put in any re-evals as needed. Discharge instructions do take a little bit of time.

Maybe i perceive I’m faster with Epic because at my other job, i see considerably less patients. Like 1 to 1.3/ hr.
 
wareagle726 said:
Could you elaborate on this a little bit? Mainly so I learn some med mal charting tidbits. Thanks.
Click to expand...

When you are sued, its years after something happened. You've seen 10's of thousands of patients since that time. Trying to recall the case based on a dictated story is a heck of a lot more defensible than something that is just a comglomerate of check boxes. Check box charting, from T-sheets to EMRs, are built solely for the purpose of billing. Not good patient care. Not good legal coverage. Billing. That's what they do well.
 
gamerEMdoc said:
When you are sued, its years after something happened. You've seen 10's of thousands of patients since that time. Trying to recall the case based on a dictated story is a heck of a lot more defensible than something that is just a comglomerate of check boxes. Check box charting, from T-sheets to EMRs, are built solely for the purpose of billing. Not good patient care. Not good legal coverage. Billing. That's what they do well.
Click to expand...

What makes it more defensible? I'm sorry if it's a dumb question. Don't have much med mal experience (knock on wood!).

I typically do a click box hpi with maybe 2 sentences of narrative. Most of my MDMs are a nice narrative. I would think that's defensible or at least not much worse than a long paragraph hpi with a similar MDM.
 
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There is no narrative, which makes trying to have any picture of what the patient actually presented with very difficult. If you have a very clear history, its easier to paint a picture in a defensible light. I guess if you put a long narrative in your MDM to tell the history, then it will help you have an idea of what happens.

What I commonly see in transfers from people that use click box histories is something like this:

CC: Weakness
Location: Generalized
Timing: 2 days
Associated Symptoms: Nausea
Course: Constant

So lets say its a 90 year old that comes in with generalized weakness and vague symptoms. How can you accurately convey what that person is there for by looking at that history above?

There are 3 reasons we chart in medicine:
1. To get paid for what we do
2. To help us paint a picture of why the person was there and what they looked like and what we did for them, in the off chance something goes wrong and we get sued 3-4 years and 10,000 patient encounters later.
3. To convey accurate information to the physician who we pass off care to (PCP, admitting consultant)

Click box charting does only the first. Where as good dictators who understand billing and coding can effectively do all 3, in less time than it takes to click boxes.
 
IMO the more vague a chart is, the worse it is to defend, and that's something I've commonly heard in risk managment talks as well. EMRs are nightmares from a defense standpoint. Because if something isn't charted, it didn't happen. So if you have a few check boxes and leave things very vague, you open the door for an attorney 4 years later to frankly make up whatever history they want, and you can't say it isn't true because you have nothing documented to the contrary other than a few boxes you clicked.
 
RustedFox said:
@CajunMedic - would you be so kind as to tell us briefly how to set up the voice commands to fill out the boxes in MediTech? My one job site uses it, and I would love to say "Insert Level 5 ROS" and have it fill out those damn boxes.
Click to expand...

So, I used the customization in MModal for it. Our version of Meditech had a free-text box for ROS, HPI ,etc. I started with a template built in Word or Notepad with what I wanted with brackets in place. MModal has a "Personalize" option on the drop down. Open that and select "new command". Type/Dictate what you want to say: "Insert Level 5 ROS" in the command box and in the text box, cut and paste your desired input and save it.
 
CajunMedic said:
So, I used the customization in MModal for it. Our version of Meditech had a free-text box for ROS, HPI ,etc. I started with a template built in Word or Notepad with what I wanted with brackets in place. MModal has a "Personalize" option on the drop down. Open that and select "new command". Type/Dictate what you want to say: "Insert Level 5 ROS" in the command box and in the text box, cut and paste your desired input and save it.
Click to expand...


Ahhh, so it doesn't fill out the clicky-boxes, it just pastes whatever text you tell it to in the "free text" field.

Gotcha.
 
Why do you need to copy and paste all imaging results into the notes? Note bloat doesn't bill better or make better notes.
thegenius said:
Do you use one of those COWs and walk around pushing it into patients rooms, or do you go back and forth between patients rooms and a desktop?

Is your general workflow see 1 patient, put in orders, dictate, see another patient and so forth...or will you see two or three patients at a time, then sit down and put in all the orders and make the charts?

I use scribes and I’m still inefficient. Prob for a variety of reasons. Statistically over the course of a year, I average 2.2 (2.18). What slows me down is 1) me... just being slow I guess. Although at the end of the day 2.2/hr isn’t that bad. 2) if I’m doing my own charts, pulling in EKGs and imaging is such a time suck. We use Cerner. Unlike labs where they are imported, I wish i could just click on a button and incorporate all imaging and EKGs. Right now it’s a copy paste thing. Imagine a trauma with a pan scan and 6 xrays. Takes FOREVER. 3) dispo instructions. I always detail mine, i try to make itemized lists. I’ve read patient compliance improves with itemized lists. But it just takes time.

I’m envious that you see as many, actually more than me and get all your charts done on time and you leave on time.

For what it’s worth...i feel I’m faster with epic than cerner. With epic...it’s one huge free text note and i use macros. And I never import imaging studies i just summarize them in my note. In epic...i type a quick HPI, I macro in a ROS, jump to the exam....put in a macro and makes edits as needed....import all labs....type my MDM. Put in any re-evals as needed. Discharge instructions do take a little bit of time.

Maybe i perceive I’m faster with Epic because at my other job, i see considerably less patients. Like 1 to 1.3/ hr.
Click to expand...
 
TooMuchResearch said:
Why do you need to copy and paste all imaging results into the notes? Note bloat doesn't bill better or make better notes.
Click to expand...

By "all", he likely means "all results for this visit".
CERNER sucks about this; you need to open the dialogue for rad results, and select/import the ones that you want.

@thegenius

Try this:

1. Click on "Launch Rad Interp (flowsheet)
2. Click on the first icon in the command bar (it looks like six blue squares being selected by a pointer) - this auto-highlights all studies.
3. Click the icon to the IMMEDIATE right of the first icon (Copy Selected Items)
4. Close dialog box
5. Right-click in the free text interpretation and select "Paste"

Voila. Batch copy-paste.
 
Expanding on what @gamerEMdoc said, I once reviewed a case for the state medical board where a plaintiff attorney spent 10 pages worth of depositions (about 30-45 minutes of time) repetitively asking clarifying questions about duration of systems because the doc's checkbox had "5-7 days" overall. How long had the patient had neck pain... 3 days, 4 days, 5 days? How about the numbness? How about the trouble urinating? And you're sure of this how? Let's go back to the neck pain. What makes you think it was only 5 days when you documented 5-7 days? Doctor, you previously testified that you thought the time was 3 days but your overall checkbox blanket statement was 5-7 days? Care to elaborate?

It was painful to read, and I cannot imagine the pain the doc was in during that deposition.
 
I'm still not sure why the radiology report (i.e. another doctor's full note) needs to be in the ED note.

Our scribes do it, but when I work alone I don't do it. No change in billing.
RustedFox said:
By "all", he likely means "all results for this visit".
CERNER sucks about this; you need to open the dialogue for rad results, and select/import the ones that you want.

@thegenius

Try this:

1. Click on "Launch Rad Interp (flowsheet)
2. Click on the first icon in the command bar (it looks like six blue squares being selected by a pointer) - this auto-highlights all studies.
3. Click the icon to the IMMEDIATE right of the first icon (Copy Selected Items)
4. Close dialog box
5. Right-click in the free text interpretation and select "Paste"

Voila. Batch copy-paste.
Click to expand...
 
GeneralVeers said:
It does make my life easier when the previous ED doc has imported studies on a frequent flier. That way I don't have to do any imaging before I kick them out with no narcotics.
Click to expand...

You love hunting frequent flyers, don't you?

I take nothing away from you. I just wonder how you don't run afoul of admin frequently.
 
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RustedFox said:
You love hunting frequent flyers, don't you?

I take nothing away from you. I just wonder how you don't run afoul of admin frequently.
Click to expand...

I do get more complaint letters than average. I always document a lot more on patients who I thin will lodge a complaint. It would be hard for them to fire me over not giving narcotic pain medications without legal ramifications.
 
TooMuchResearch said:
I see. In Epic it's all so easily available, I see no benefit in making a novella of my note.
Click to expand...
My epic note automatically imports everything including imaging, but I do think it makes the note appear cluttered. Concise short notes are much easier to read. I wish there was a way to have Epic import only the short impression of the radiology read instead of the whole report.
 
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TooMuchResearch said:
I see. In Epic it's all so easily available, I see no benefit in making a novella of my note.
Click to expand...

I'm with you on brevity. CERNER makes the things that should be automatic (importing relevant data) a manual and tedious task. This is the ONLY thing that MediTech gets right.
 
thegenius said:
Do you use one of those COWs and walk around pushing it into patients rooms, or do you go back and forth between patients rooms and a desktop?

Is your general workflow see 1 patient, put in orders, dictate, see another patient and so forth...or will you see two or three patients at a time, then sit down and put in all the orders and make the charts?
Click to expand...

No, we tried using COWs at one time but I got such a back ache toting those things around. I don't use them anymore.

Honestly, I typically will put in orders based on the CC and triage notes if it's straightforward. I rarely need to change my chest pain, n-v-d, female belly pain, syncope, dizziness, etc.. order sets. I can always add or delete after I see them but at least it gets the ball rolling. If I'm not doing that, I like to enter orders after every 1-2 pt's I've seen. I'll grab the closest workstation and put them in, scan the board, pick up more pt's, see what's pending on some of my other ones and then go see 1-2 more. I like to dictate on average every 3rd patient, but sometimes I'll see 4-5 without starting charts though I don't like to go over 5. I knock out HPI, ROS, PE and if I have a good sense of the dx, I'll even fill that in too along with discharge instructions and even prescriptions. Anytime an EKG tech brings me an EKG, I enter some annotated abbreviations in the comments field of Cerner next to the pt's name so I can remember it later when transcribing into the chart. I have macros for ROS and PE and smartphrases for components in my MDM or other fields. The only components that I'm really dictating are HPI and MDM.

I'm disciplined about making sure that I completely finish each discharged pt's chart. It takes a few extra seconds but ensures that I never get behind. So, when I click the discharge order, I'm also providing a final signature on the chart. Admissions get admitted and I'll generally complete those in the next few minutes also before I get up to see anyone else. I'm really OCD about it.

2.2pph is a great pace though if that's what you're doing. Keep in mind that so many things are dependent on the department and not the physician. In general, we are a very little part of the throughput issues in spite of what nursing management would like to have admin believe. Things like having enough techs, nurses, optimal nursing/pt ratios, timely blood draws, radiology, transport, etc.. All these things can make a huge difference in not only how quickly we can see pt's, but also how many we can see in a single shift.

I've found that since going without a scribe, I spend less time dictating to them (and correcting or educating them) and more time dictating into my microphone.
 
The ability to easily pull that stuff is epic build dependent. I could in residency, I can't now, and I don't want to.
KGflyboy said:
My epic note automatically imports everything including imaging, but I do think it makes the note appear cluttered. Concise short notes are much easier to read. I wish there was a way to have Epic import only the short impression of the radiology read instead of the whole report.
Click to expand...
 
Interpreting the ECG in your note increases your E&M complexity. This is separate from billing for the ECG. So my note says I personally interpreted the ECG. Separately, there is the paper ECG with my signature that we bill for that partial RVU.
thegenius said:
EKGs bill higher...there is a CPT Code for it and it’s worth like 0.24.
Click to expand...
 
It's important to keep in mind your audiences when writing a note. You have 3: Medical Billing, Patient Care (other doctors), Medico-legal (lawyers).

Like Gen Veers, I advise a combination of check boxes and free text.

Billing -- check boxes are great. But make sure you know what your standard auto click macro is checking so you can alter it as needed.
Patient Care -- this is where free texting / dictation comes into play. HPI & MDM. Important exam findings too.
Medico-legal -- again free texting / dictation is important for this. Adding in negative red flag items, differential, shared decision making, etc. Can be done with macros too.

Really the meat of the chart is going to be free texting the MDM. Then check boxes should only take 20 seconds or so. I am probably a little slower than Gen Veers, but generally try to get a single chart finished in < 4 min.
 
RustedFox said:
I'm with you on brevity. CERNER makes the things that should be automatic (importing relevant data) a manual and tedious task. This is the ONLY thing that MediTech gets right.
Click to expand...

I think there are some Cerner builds or modules that can import radiology results. Maybe even EKGs?

The question becomes whether we need to import either. I do know that interpretation EKGs pays you money (CPT 93010, worth 0.24 RVU), but I don’t know if importing radiology reads makes even a lick of difference.

And if you get sued, the entire chart / encounter gets subpoenaed, so the radiology results will be there.

I think you just have to mention that you saw the Rads reports and acted on then accordingly.
 
thegenius said:
I think there are some Cerner builds or modules that can import radiology results. Maybe even EKGs?

The question becomes whether we need to import either. I do know that interpretation EKGs pays you money (CPT 93010, worth 0.24 RVU), but I don’t know if importing radiology reads makes even a lick of difference.

And if you get sued, the entire chart / encounter gets subpoenaed, so the radiology results will be there.

I think you just have to mention that you saw the Rads reports and acted on then accordingly.
Click to expand...

Reasonable actions; but I really like it when OtherDoc imports the labs/rads into their chart so I can see it all in one simple flow when I'm the next to see the patient. Thus, I act accordingly. I work with 2 docs that are very lazy about this, and its a pain in the ass to chase down lab results/etc.

Plus, if you're (I know you're not) an MLP; then you better damn well have everything in-place when I review the chart. If I demand that of my MLPs, then I best take my own medicine.
 
thegenius said:
I think there are some Cerner builds or modules that can import radiology results. Maybe even EKGs?

The question becomes whether we need to import either. I do know that interpretation EKGs pays you money (CPT 93010, worth 0.24 RVU), but I don’t know if importing radiology reads makes even a lick of difference.

And if you get sued, the entire chart / encounter gets subpoenaed, so the radiology results will be there.

I think you just have to mention that you saw the Rads reports and acted on then accordingly.
Click to expand...

Blowing in rads reads and labs just adds to note bloat. Just comment on your interpretation of them in your MDM. They're part of the chart, just like the triage/nursing notes.
 
Fox800 said:
Blowing in rads reads and labs just adds to note bloat. Just comment on your interpretation of them in your MDM. They're part of the chart, just like the triage/nursing notes.
Click to expand...

... and if your interpretation is incorrect?
 
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GeneralVeers said:
Right. The checkboxes are for billing as far as I'm concerned. I love how Cerner will tell me if I've hit all the points needed for a level 5.
Click to expand...

Yep.

HPI: Click until the little meter says that I have a Level 5 chart. Then, say what you actually mean in the last line.
ROS: Macro. Make corrections as needed.
PMHx: Click "reviewed in chart". No more.
PE: Macro. Make corrections as needed.
Labs/Studies: Import this. Takes five clicks at most.
MDM: Autotext city.
Dispo: Macro-time again. KTHXBYE.
 
TimesNewRoman said:
So we’re all just gonna let that go?
Click to expand...

Yeah. Okay; I'll bite.

I have a passion for my wife, baseball/hockey cards, and golf.
Nobody has a passion for billing/coding.
The millennials have taken this word "passion" and redefined it to mean "passive interest".

I read an article a few days back entitled: "20 words you should never use to describe yourself" in the context of job-seeking/resume writing/etc.

It was basically a list of words that millennials use every other sentence.
 
KGflyboy said:
My epic note automatically imports everything including imaging, but I do think it makes the note appear cluttered. Concise short notes are much easier to read. I wish there was a way to have Epic import only the short impression of the radiology read instead of the whole report.
Click to expand...
FWIW, I write my (non-EM) notes in SAPO format. It's not as cool sounding as SOAP, but it gets information across to those who rely on it for further patient care, while ensuring the bean counters get their beans.
 
RustedFox said:
... and if your interpretation is incorrect?
Click to expand...

I don't understand what you're getting at here. The imaging is attached to the chart, just like the labs, every single order you signed, nursing notes, triage information, etc. I guess if you misinterpreted the final read in your MDM, you could get boned. Are you worried rads is going to addend their final read and make you look like a bonehead and make it look like you said the wrong thing? I guess theoretically that could happen.

I just summarize it to add to the complexity of my MDM.
 
Why would some of you guys leave out labs and rads from your ED note? It makes the chart readable. There's nothing worse than reading over a note that a colleague saw 2 days ago and having to spend several extra minutes looking up labs and imaging and anything else not included in the note.

Plus, on the small chance it goes to a plaintiff lawyer for possible litigation. The first thing he's going to do is find his "expert witness" or whatever doc he pays on the side to review charts for him and ask him to read over and and let him know whether he's got a case or not. That's the last person you want getting confused as they peruse back and forth through your note and radiology reads trying to figure out which one was from this visit and which was from the next visit, etc..

I consider it just good form to make the note as readable as I possibly can for any physician looking back on my note or otherwise.

If you're talking about a specific EMR that hard links imaging and labs to your specific encounter then I think that would be fine.
 
Groove said:
If you're talking about a specific EMR that hard links imaging and labs to your specific encounter then I think that would be fine.
Click to expand...

Epic does this. Everything is permanently linked to the ED visit. Every order, every result, every note, every vital sign.
 
Fox800 said:
Epic does this. Everything is permanently linked to the ED visit. Every order, every result, every note, every vital sign.
Click to expand...

Ah, well in that case I guess it's not as big a deal. Cerner has a more difficult time linking disparate data from different sources so I put it all in the note. I vaguely remember Epic doing a better job with this kind of stuff but it's been years since I used it.
 
Yeah the Epic stuff is all linked and is so much more readable when not plastered into a note. If I'm seeing a bounce back, referral, whatever with recent relevant notes, I scan the MDM and based on that might quickly review labs, imaging, etc. All very easy to do in Epic.
Groove said:
Ah, well in that case I guess it's not as big a deal. Cerner has a more difficult time linking disparate data from different sources so I put it all in the note. I vaguely remember Epic doing a better job with this kind of stuff but it's been years since I used it.
Click to expand...
 
Fox800 said:
I don't understand what you're getting at here. The imaging is attached to the chart, just like the labs, every single order you signed, nursing notes, triage information, etc. I guess if you misinterpreted the final read in your MDM, you could get boned. Are you worried rads is going to addend their final read and make you look like a bonehead and make it look like you said the wrong thing? I guess theoretically that could happen.

I just summarize it to add to the complexity of my MDM.
Click to expand...

Fair question, I wasn't very clear when I wrote this last night. Maaan, was I tired.

Its just as easy to make a mistake summarizing the data as it is any other task. Lets say you're getting ready to dictate your MDM, and you get incepterrupted by an RN. You stop what you're doing, look up the other data, and then dictate on THAT data in the FIRST chart. Also; lets say you interpret "acute hyponatremia in the setting of renal failure" but the patient is really neither (pseudohyponatremia due to hyperglycemia, and patient is actually at their baseline renal function). Can happen.
 
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