How to get off your shift on time

[Aloha Kid]

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I'm in my first year out practicing. I've notice I am often very slow getting off my shift. I'm probably averaging near 2 hours post shift trying to finish dictations and wrap things up. One of my biggest problems is keeping up with charts and dictations. I find it hard to stop and dictate when there are more patients to be seen and know I have to get better at this.

My production numbers are good, but when averaging the extra hours I stay behind it's simply average to slightly above average. Tonight I felt pretty busy seeing about 2.3 pt per hour, but I was working with a slower doc and felt like I had to pick up the charts to keep the ER going.

I work for a base hourly salary w/ RVU incentives that are press ganey modified. We share the rack and are not podded up. RNs have free reign and access to any doc they want when there are sick patients. Our site average is right about 2 patients per hour.

Anyone have any secrets on how to get out on time?

 

[n2b8me]

😉

 

[Arcan57]

From your next shift through the rest of your career, never get more then 3 charts behind on your dictations. Unless there are multiple consecutive codes, don't break this rule. Dictate somewhere that is outside of the normal work-flow area after signout, so you don't get stuck following up on results of patients you signed out an hour ago. Try not to pick patients up an hour before the end of your shift unless you can easily sign them out.

 

[GeneralVeers]

There are several factors that can determine whether or not you stay late. If you are single coverage or double coverage it can make a big difference.

If I'm on a shift with at least double coverage I never pick up any big work-ups (like belly pain) within 1 1/2 hours of the end of my shift, and I don't pick up anything else in the last hour if I have active patients. I make sure to dictate on every chart before the patient leaves the E.D. There are at least three people in my group who save their dictations for the end of shift, and they are often there 2 hours past their shift time just dictating (they aren't even top RVU producers). One thing that will really help you out is just to order a CT scan early. If you think someone may need one, you might as well just save yourself some time and get it done. Don't wait for labs before you decide.

If I'm single coverage it's more problematic. Generally our single coverage is at the end of night shift when I go home at 6 AM. I don't see any new patients (unless they are critical) after 5 AM but I will get some orders started on obvious workups like chest pain, and have the 6 AM doctor see them.

Generally I'm able to get out most shifts within 1/2 hour of my finish time, and remain one of the top producers.

 

[Aloha Kid]

So I actually kept up with my charting reasonably well. Only about 4 deep the whole time. Got off 1 hour post shift ended and also helped one of my partners with a cric as well. So glad that wasn't my case.

In summary this is what I have so far.

1. Never get behind with your charts.
2. Cherry picking is okay the last 1-2 hours of the shift
3. Order CT scans early, especially in the last few hours of your shift.
4. Sign out can be a life saver (if your department is sign-out friendly)
5. End of shift dictations should be done privately - away from distractions
6. Disposition quickly near the end of shift - It's "go time" the last 2-3 hours

I've heard lots of good things about scribes. They say it doesn't necessarily help productivity but actually helps docs who are staying late, wrap up faster. Probably because the charts are done real time. Anyone have scribes?

 

[Arcan57]

We have scribes, although we use the T-sheet system so my ability to get out on time does not change much. Scribes do seem to add ~3 patients/shift to my productivity, mostly by doing discharges on our ridiculous EMR system (Exitcare).

 

[digitlnoize]

We have scribes, although we use the T-sheet system so my ability to get out on time does not change much. Scribes do seem to add ~3 patients/shift to my productivity, mostly by doing discharges on our ridiculous EMR system (Exitcare).

I was a scribe, now a 3rd year medical student.

Get scribes. Pre-meds will do it for next to nothing, I made $8/hr. I did all the charting for my assigned doc on my shift. From H&P to D/C. Made their lives sooo much easier. I sit there typing as fast as I can go, while they kick back and chit chat, then we go see the next couple of patients.

Our docs almost always got out exactly when their shift ended. We did handoffs to the incoming docs and had a good team and good scheduling. Wait times were <20 minutes from door to doc, usually much less.

Our docs rarely had to dictate. We just listened during the interview and typed up everything on our own. They'd usually dictate the exam to us when we left the room, if it wasn't obvious already. They'd sometimes help out with chart entry if things got crazy. Like, I'd be working on the H&P and they'd enter orders or start on the discharge notes. We could have a patient's discharge papers in the nurses hands within a couple of minutes of walking out of the patient's room.

It wasn't uncommon to see 6 or so pt/hour if we were that busy. We could've probably handled 8-10/hr if we HAD to, but we were a small-ish ER and rarely got THAT busy. We could usually predict busy days in advance (sporting events, etc) and scheduled extra help accordingly.

Get a scribe.

 

[Aloha Kid]

Our site is picking up scribes. We've selected a few and are starting training. I'm very interested to see how this is going to work out. I'm optimistic about it.

Shift number two under my belt and I kept up with charting well. Only got 2 deep. Was ready to leave 45 minutes post shift.

 

[NinerNiner999]

Try to mentally include the dictation as part of the patient process and make it a point to have a note dictated either before your print out the discharge instructions, or immediately after you hang up with the admitting doctor. It took me a week to get used to this but now, I never have any outstanding dictations and I'm the fastest in my group.

Interestingly, when I first started my job, I reviewed my first three months of dictations. When I received my patient list from MR, it included a dictation start and stop time, along with a total for dictation time for each month. The total dictation time averages 8-10 hours per month - an entire shift worth!

 

[Aloha Kid]

Wow, that's crazy, but easily conceivable that we average a 8-9 hours of dictations per month.

 

[xaelia]

Wow, that's crazy, but easily conceivable that we average a 8-9 hours of dictations per month.

I spent 8-9 hours a shift typing notes into Epic.

Almost. So burdensome.

 

[Lumberg]

I'm in a FFS group that works mostly 8's but we do some 12's at a free standing facility. We do not sign out until the pt is either on the launching pad for d/c or admitted (unless it's psych and we're in in frantic bed search...but those pt are essentially dispo'd anyway). I usually leave 1 1/2 hrs after my shift ends but occasionally walk out right on time or get hung up w/ a late resuscitation. I only dicate codes, weird pt encounters, CX call backs, etc. We have computer based charting and it is done in the room by me at the pts bedside. We have scibes approximately 50% of our shifts and they are a godsend. They're pretty cool to interact with. Most of them are pre meds and they are all eager and hard working. I now work in a community ED (100k visits/yr) and really like teaching the scribes basic clinical stuff and helping them navigate AMCAS, MCAT, relationship crises, tattoo choices, etc, etc.
I'm sure you all can appreciate the complexities of signing out in a FFS model. If you leave a pt w/ a pending CT and the following doc has to hang abx, call surgery, tell the family and admit the pt...who gets to bill for that encounter? In order to avoid those issues we have all decided that we don't sign that stuff out. My residency was set up very similarly to this and it was easy for me to make the transition (i'm only 3 yrs out) but some of our new docs are used to walking out the door at 3pm and had to adjust. I usually don't pick up any non critical pts in the last half hour unless it's an easy in/out thing (I have been burned before!). Abdominal pain in the last hour, I'll usually poke my head in and start the w/u (blood, ua, preg, IVF, pain meds, nausea meds, +/- oral contrast, U/S, etc.) and let my partner take it from there if they're not in extremis. In a FFS model it helps that you are naturally incentivized to see as many pts as you can. We're extremely well compensated and I look at my 10+ hr shift as routine. In order to help you get out on time, I think it helps to begin planning your exit stategy and make sure everything is ordered, all studies are being run , etc. How many times have you all been ready to dispo a pt and the urine was never collected, HCG not done, raiology "never got" the CT order, lab "lost" the blood, urine, stool, CSF, etc, etc. I do a complete review of all my pending pts approx 2 hrs before my shift ends to ensure all that stuff is where it needs to be. The other component is simply time and experience and you'll see yourself getting things ramped up early and you'll get out earlier. Hope this helps,'Berg

 

[deleted65604]

If docs are walking off their shift 5 minutes after their shift 99% of the time, hats off to them. I still haven't figured it out. By the time I check on my patients, talk to them every half hour or hour, get them something to drink, do procedures, pick up new patients, I tend not to chart much until the end of my shift. I don't mind staying after my shift if it means I got one less patient complaint and one more patient who really understood their diagnosis.

A couple of my partners walk out consistently right at the end of their shift, and if that means dumping...I mean signing out 4 patients to me, they don't care. Nothing to ruin the start of your shift like getting a patient signed out to you with a pulse of 160 and a pressure of 80 systolic and the doc telling you, "I just think they're a little dehydrated, they're getting a second liter of fluid and then decide on disposition." (Patient ended up being in one of those atrial flutter rhythms that looks like sinus tach).

We do paper t-sheet charting, and those docs put one sentence medical decision making explanations regardless of the complexity of the patient. Our boss consistently chides and encourages them to give a more accurate picture of the clinical encounter and to chart defensively regarding every emergency that has been ruled out. One doctor told a nurse, "I don't know how he expects us to do that, I just don't have time". Translated, I could chart more completely, but there is no way in H E double toothpicks that I am going to spend minute more in this place than I have to. When you come on to shift, those docs have rarely seen the patients and you end up walking into rooms where people have been waiting for very a very long time for the sole reason that the previous doc just had to get home on time and was busy charting rather than actually taking care of patients.

Maybe we should care a little less about staying after on a shift and a little bit more about our colleagues. Now, if you are like niner and can do it all and see more patients than anyone in your group, great, but for the rest of us, who aren't super-heroes, we need to be cognizant of pulling our weight.

I've noticed that 99% of people feel like they work harder than anyone else. The way you percieve yourself and the way you are percieved are often very different.