How to be faster at H&P's as a resident

[bio-Psych-social]

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Hello SDN,

Psych intern here. I just came off of a call day and saw 5 new patients which took me literally 13 hours.. plus I had med students with me which makes me even slower.

I've been on psych for ~3 weeks total after being off service a few months. I tend to see 7 patients daily which includes a mix of new and old and some days I'm done after 7a-1p, other days I'm staying until 5-6pm. I'm trying to work up to seeing 10 patients on service with new/old patients as that's the expectation of us by the end of intern year.

I have tried chart checking less, but then I feel I can't thoroughly answer some of the Attending's questions which stresses me out. I am trying to make my assessments shorter but my notes are still otherwise lengthy with all of the questions that our notes want. I am down to 1 hour per H&P from start of note to finish (not including times chart checking and see patient) from what used to be 90 minutes. These are also very psychotic patients which people say should be easy, but I don't find that to be the case for me. I feel like the notes are so long and some of the patients are still so medically complex that I find myself reading their medicine notes as well. I'm scared that I won't improve and will be singled out as a slow resident or won't achieve work life balance and will ultimately burn out. Please help me. Any tips? Thank you!!

 

[Bartelby]

Of course as you gain experience you will gain efficiency. That will include rapidly picking up on what matters and making sure you highlight that information in your own mind.

For now, use a system that moves you quickly through the new assessment. As you do all this, keep in mind that documentation can be pretty succinct. Think about what you like to see in other peoples' notes. It probably isn't every detail of the current conflict the patient has with their cousin's girlfriend, but early on there can be a tendency to transcribe a lot of marginally relevant information. Feel free to jettison most of that and find ways to summarize it (processed interpersonal stress in pt's life and reviewed boundary setting / social skills).

Get your workflow going, which for a new consult should be something like:
-Get the page. Immediately pull up the chart and start a note.
-Call the consult back. Jot relevant notes in the subjective section as you chat. (5 min)
-Spend 15 mins on chart review. See the most recent psychiatry note (if any), any really relevant medical notes (focus on assessment and plan), and anything else relevant based on your initial review. The whole time quickly jot notes into your open note template. You will have a pretty good skeleton of your note before you even see the patient.
-Talk to the patient, but limit to 30 mins (less for simpler issues, or where you already have most of the data and you can more quickly verify it). Where possible bring your trusty template and jot notes as you talk. Much of that can be included without much editing (your note does not have to be beautifully written, telegraphic snippets are fine).
-Based on the chat look up any additional chart information you need, call for collateral if needed (this doesn't apply for most consults), and do a bit of cleanup of your note. Add a good but focused assessment and plan. (15 min)
-Call back to provide recs (5 min). Enter orders if needed for admissions (5 min).

As you can see, especially if you shave the interview portion down a bit you can keep most consults within about an hour. For totally new consults around one hour is pretty efficient for good work, and not too bad using the above workflow.

For admissions that already have a full assessment, you can simplify to:
-Do your note review + charting (15 min), with a focus on the already-existing assessment
-Talk to the patient briefly (10 min)
-Enter orders (5-10 min) and do any miscellaneous tasks like updating the nurses
-Remember the day team will be in tomorrow, you are just tucking in the person overnight and ensuring anything urgent/risky gets addressed!

If you are teaching med students do at least some work in parallel. They should be writing notes, reviewing charts, etc. while you also do productive work. That makes up at least a bit for the time spent teaching.

 

[brosa]

What is taking the most time? The HPI, the assessment, coming up with a plan, reviewing chart, the interview per se?

The most common mistake (it is not really a mistake, but it is not very efficient) for PGY1s is to simply write too much on the HPI. Too many details can be detrimental because it takes the focus away of what matters. I've seen a note that had a whole paragraph describing the patient's clothes, and they were normal. Not the description of odd, disorganized, or manic clothing, just completely normal things. This kinda of thing is useless and takes time from proper patient care.

Try to write less and be more concise, that tends to help a lot. It is completely normal to be slower at the beginning, you will get more efficient with time and do better, so also don't worry so much about it.

 

[brosa]

Oh, another VERY important advice: do not double work.

I have seen many many residents opening a chart, reviewing a lot, then they open a note and start writing. They will forget information and go back to the chart to review it again. DO NOT DO THAT. When you are reviewing a chart, start the note and pull as its own window. Write what you find in a way that is ready to go.

Bad example:
18yo psychosis, hospitalized, drugs, college, job.

Many residents will write like this, with the idea of going back later and fixing it. Just do it from the zero, it doesn't that that much longer and it makes the process faster overall.

Good example:

Per chart records, first episode psychosis happened at 18yo, leading to a hospitalization. UDS positive at the time for marijuana. Patient dropped from college and could not function at his job after.

That way you don't have to keep going back, which saves you a lot of time. Not double working may be the best advice I have for you, since I have seen so many residents doing it.

 

[Celexa]

Oh, another VERY important advice: do not double work.

I have seen many many residents opening a chart, reviewing a lot, then they open a note and start writing. They will forget information and go back to the chart to review it again. DO NOT DO THAT. When you are reviewing a chart, start the note and pull as its own window. Write what you find in a way that is ready to go.

Bad example:
18yo psychosis, hospitalized, drugs, college, job.

Many residents will write like this, with the idea of going back later and fixing it. Just do it from the zero, it doesn't that that much longer and it makes the process faster overall.

Good example:

Per chart records, first episode psychosis happened at 18yo, leading to a hospitalization. UDS positive at the time for marijuana. Patient dropped from college and could not function at his job after.

That way you don't have to keep going back, which saves you a lot of time. Not double working may be the best advice I have for you, since I have seen so many residents doing it.

Almost every slow resident I have worked with doesn't understand the double work problem, and the ones that stay slow are the ones who never figure out how to stop doing it.

 

[Candidate2017]

Calm down. You're a new intern. Show me an efficient intern, and I will show you an intern who makes lots of critical errors.

You should be slow because you don't know, and you also need time to absorb/learn. 5 H&Ps is a lot for a new intern. But, you say it's an anomaly, and you are done between 1-6 pm. That's normal. You should also ask your seniors for tips. They remember all their intern year mistakes, unlike attendings. As for medical complexity, you probably haven't had IM rotations, so everything is medically complex.

Your attempted solution of less chart checking is wrong. I expect an intern to spend lots of time looking at the chart. You don't yet know the difference between efficiency and omissions. Efficiency comes from experience. Experience comes with time. Put in the time. You've seen a building being built? It looks like a gaping hole in ground for years, zero progress. Then one day the foundation is finished, and the building rises up in a relative blink of the eye.

Anyway, you have a lot of cognitive errors, including assuming your performance at the end of PGY-1 will be the same as today's performance.

 

[comp1]

Definitely concur that speed should not be your primary focus in September of your intern year. Yes, your attendings will be putting it in your evals, but remember they have to put something and that's not a bad thing for them to put. For me personally, I focus on chart review and use patient interviews in an extremely targeted manner specifically to fill in holes or points of confusion in the chart. Charts are already written in the language that you need to generate. The patient themselves most definitely will NOT speak in the language you need, particularly if you ask more open ended questions. Translation takes a lot of time and energy. Now this of course doesn't apply to truly brand new dropped in from the sky, chart and remote records empty, patients, but they should be relatively rare.

 

[FlowRate]

Hello SDN,

Psych intern here. I just came off of a call day and saw 5 new patients which took me literally 13 hours.. plus I had med students with me which makes me even slower.

I've been on psych for ~3 weeks total after being off service a few months. I tend to see 7 patients daily which includes a mix of new and old and some days I'm done after 7a-1p, other days I'm staying until 5-6pm. I'm trying to work up to seeing 10 patients on service with new/old patients as that's the expectation of us by the end of intern year.

I have tried chart checking less, but then I feel I can't thoroughly answer some of the Attending's questions which stresses me out. I am trying to make my assessments shorter but my notes are still otherwise lengthy with all of the questions that our notes want. I am down to 1 hour per H&P from start of note to finish (not including times chart checking and see patient) from what used to be 90 minutes. These are also very psychotic patients which people say should be easy, but I don't find that to be the case for me. I feel like the notes are so long and some of the patients are still so medically complex that I find myself reading their medicine notes as well. I'm scared that I won't improve and will be singled out as a slow resident or won't achieve work life balance and will ultimately burn out. Please help me. Any tips? Thank you!!

If you're completing a start-to-finish moderate-complexity new patient H&P in 2-3 hours then you are completely on track for appropriate timeliness as an intern.

The fact that you said psychotic patients take you more time makes me really curious. Is that because you spend forever trying to coax something useful out of the patient during the interview or that you spend way too long providing direct quotes of their disorganized thoughts in the HPI? (Or both? Or something else?)

Always keep in mind your goal during patient interactions. There are all sorts of tangents you can go down and not all of them are oriented toward that goal. For example--speaking as someone who hasn't done inpatient in a long time, so take this with a grain of salt--with an inpatient H&P your goals are:

Mandatory:
1. Arrive at a reasonable initial independent diagnostic impression
2. Determine any acute medical or psychiatric safety concerns (acute illness, significant SI, violent ideation, true allergies)
3. Formulate an acute treatment plan (safety, initial treatment, PRN treatment, level of observation), ideally with patient agreement

Ideal:
4. Determine barriers to eventual discharge
5. Identify the "why/what" that led to them being hospitalized NOW
6. Establish some degree of therapeutic alliance (Especially if this will be a longitudinal patient of yours)

 

[calvnandhobbs68]

I've been on psych for ~3 weeks total after being off service a few months. I tend to see 7 patients daily which includes a mix of new and old and some days I'm done after 7a-1p, other days I'm staying until 5-6pm. I'm trying to work up to seeing 10 patients on service with new/old patients as that's the expectation of us by the end of intern year.

Don't get so so stressed by the 10 patients total thing. 3 new patients and 7 followups is way different than 7 new patients and 3 followups. You'll be able to do it no sweat by the end of the year.

 

[Orgone]

That's normal. You should also ask your seniors for tips. They remember all their intern year mistakes, unlike attendings.

This is an excellent point.

There's the saying "don't know what they don't know." After a few years of attending-hood we don't know what we didn't know. It's easy to forget what it was like before we developed our ruthless hard-earned filter for what is relevant.