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Increased Outpatient Efficiency
- Thread starter Kabin
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For a 30 minute med check I liked the breakdown of 5:10:5:10
5 minutes to let someone talk about whatever they want, 10 minutes for focused questioning, 5 minutes for wrap up and planning, 10 minutes to document.
Also use good self-report q's/sx inventories like the QIDS-SR while the pt. is in the waiting room, which saves time on crap like going over symptoms.
5 minutes to let someone talk about whatever they want, 10 minutes for focused questioning, 5 minutes for wrap up and planning, 10 minutes to document.
Also use good self-report q's/sx inventories like the QIDS-SR while the pt. is in the waiting room, which saves time on crap like going over symptoms.
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I don't know if this is the most efficient way of doing things. It definitely is pretty comprehensive. Going over symptoms is the main part of a med review and not "crap".
Most stable patients needing med review will not be able to free-associate for 5 minutes.
I don't think there is one way to do a med review. It varies from patient to patient. Stable patients don't need more than 10-15 minutes. On the other hand, patients who are not stable may need upto 20 minutes.
Why do you need 10 minutes to document for a med review?
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Wasn't trying to be offensive, but I've found that symptom checklists alone furthers the mentality that "my depression is acting up," essentially externalizing all aspects of the illness and the illness itself, and can lead to somewhat reductionistic view (by the patients and providers), rather than acknowledging psychosocial factors that can weigh into symptoms. Minutes spent on "how's your sleep, how's your mood, how's your appetite" could be used for a lot of other things. Just my $.02 on efficiency. But I agree with WoW, there is no one way to do things.
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I don't think you were offensive.
I assume if a patient checks sleep problems on his QIDS-SR, one would ask more about their sleep pattern, possible reasons for insomnia etc. If there is a check on Mood changes, ones would ask follow up questions on mood. This will of course be interspersed with possible stressors/psychosocial factors affecting these changes. I believe all this is basically going over symptoms and factors possibly influencing the symptoms. The bottomline is that med review is all about symptoms. The differences may exist in how much detail you are willing to go into.
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Well, per my status I'm very unqualified to comment on this, but I just read an article that's short and might be worth a read. It's broad, but might help you tailor your own system based on its principles.
Anyway
Relationship, communication, and efficiency in the medical encounter: Creating a clinical model from a literature review
Mauksch, Dugdale, Dodson, and Epstein
http://archinte.ama-assn.org/cgi/reprint/168/13/1387
~7 pages of content
Anyway
Relationship, communication, and efficiency in the medical encounter: Creating a clinical model from a literature review
Mauksch, Dugdale, Dodson, and Epstein
http://archinte.ama-assn.org/cgi/reprint/168/13/1387
~7 pages of content
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A med management encounter can take from 5 minutes to 60 minutes (rarely more) and depends on a lot of things.
Do you know the patient well...for example new pt vs 6th visit and how well are previous notes documented.
How reliable is the patient as a historian
How complicated is the patient
Are you going to change anything, lifestyle, psychosocial, consults etc.
Are you going to change medication
Will you change to a new medication
Do you need to do some therapy...you should be doing some but its not always needed.
But your question seems more broad. What exactly are you having trouble with in each of those areas. Perhaps you need to work with a mentor/have someone sit in with you to see what you are doing wrong.
Do you know the patient well...for example new pt vs 6th visit and how well are previous notes documented.
How reliable is the patient as a historian
How complicated is the patient
Are you going to change anything, lifestyle, psychosocial, consults etc.
Are you going to change medication
Will you change to a new medication
Do you need to do some therapy...you should be doing some but its not always needed.
But your question seems more broad. What exactly are you having trouble with in each of those areas. Perhaps you need to work with a mentor/have someone sit in with you to see what you are doing wrong.
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When I work in the outpatient clinics:
Especially for new patients, I do like symptoms checklists in the waiting room. Make sure there is a way for the responses to stay hidden from office staff - so patients don't have to worry about who else sees them - even if it's simply that the pt brings it in from the waiting room. When I go to a new doctor's office, there are some responses that I will not write, and instead write "ask me inside the exam room." I don't mean to be rude, but there are somethings that I just don't want the clerical staff to accidentally see.
Whether paper or computer, I document during the appointment. It seems like pt's would find this annoying/distracting, but I found a things to make it work:
1) While the pt is actually speaking, I concentrate on looking at the pt. If I make any notes, they are tiny. However, when the pt implies something he's saying is important, I make sure to give a change of expression, and then look down to make a short note (even if I don't think it's important). This shows people you are listening and responding to what they say. If I need to make a note that takes more than 1 second, I make a quick remark (like "Oh, no. That's awful.") to give myself a couple seconds before the pt goes on speaking and I need to be looking at him and not the paper/computer.
2) When I'm speaking, that's when I make more extensive notes, complete elements of the MSE, begin making Tx Plan notes, etc. It seems people are just not that interested in eye contact when they are not the ones speaking.
Using those two principles, I've documented entire new pt evaluations, reached an agreed treatment plan, written prescriptions, etc. in 45-50 minutes. Then sometimes the pt asks, "So now you have to write down everything? How long does that take?" When I explain that I'm nearly done because I've been writing the whole time, they are amazed. "When did that happen? I never saw you write a thing."
Also, I have a handout form with checkboxes and fill-in instructions, that reduces the time it takes for the "okay, so before the next appt..." section at the end of the appointment. It also means...
A) I don't forget to give important instructions (like NO ALCOHOL OR DRUGS)
B) There is a written record of my instructions, including med taper/titration
C) There is an opportunity for pt to ask questions about the details before leaving.
All nice to have should there ever be a legal question.
One other thing I've been advocating, but can't get the outpt clinic to agree to:
Assign appt times 15-20 min before the time I expect to meet the patient, e.g. if my calendar say the appt is 2pm, the patient's appt card says 1:45.
Most every place I've worked has about 20% no-show rate.
People can have trouble parking, busses run late, etc, so I don't want to cancel the appt until ~ 15 minutes after the time on the appt card. If we set the appt 15 min before, we can declare the pt "late" upon 15 min past the time on the card and not feel immoral. So, if the appt card says 1:45, and the pt arrives past 2pm, then it seems very reasonable for me to have moved onto something else, like seeing an "urgent care" walk-inpt who was waiting for a chance to be seen because of some emergent problem. This is very different than simply telling patients "please arrive 15 min before your scheduled appt" because that Never seems mandatory - even when I'm the patient at a doctor's office. But most everyone understands that if you arrive 15 min PAST the time on the appt card, that your are "LATE" and the doc may have had to move on to another patient, and your appt will be re-scheduled or you can wait to see if there is another no-show later in the day.
Another item, try to arrange to have phone/fax messages attached to the chart before being given to you. This may seem elementary, but some clinics don't customarily do this. If you get the messages and fax refill requests, etc. and then have to request the chart, it all takes so much longer. If office staff are saying that takes too much of their time, point out that this system allows them to take several messages to med rec's at once (like once every 2 hours), reducing the total time of running back and forth. If they insist that you see the message first and wait for you to request the chart, they will have to go to/from medical records many more times.
Especially for new patients, I do like symptoms checklists in the waiting room. Make sure there is a way for the responses to stay hidden from office staff - so patients don't have to worry about who else sees them - even if it's simply that the pt brings it in from the waiting room. When I go to a new doctor's office, there are some responses that I will not write, and instead write "ask me inside the exam room." I don't mean to be rude, but there are somethings that I just don't want the clerical staff to accidentally see.
Whether paper or computer, I document during the appointment. It seems like pt's would find this annoying/distracting, but I found a things to make it work:
1) While the pt is actually speaking, I concentrate on looking at the pt. If I make any notes, they are tiny. However, when the pt implies something he's saying is important, I make sure to give a change of expression, and then look down to make a short note (even if I don't think it's important). This shows people you are listening and responding to what they say. If I need to make a note that takes more than 1 second, I make a quick remark (like "Oh, no. That's awful.") to give myself a couple seconds before the pt goes on speaking and I need to be looking at him and not the paper/computer.
2) When I'm speaking, that's when I make more extensive notes, complete elements of the MSE, begin making Tx Plan notes, etc. It seems people are just not that interested in eye contact when they are not the ones speaking.
Using those two principles, I've documented entire new pt evaluations, reached an agreed treatment plan, written prescriptions, etc. in 45-50 minutes. Then sometimes the pt asks, "So now you have to write down everything? How long does that take?" When I explain that I'm nearly done because I've been writing the whole time, they are amazed. "When did that happen? I never saw you write a thing."
Also, I have a handout form with checkboxes and fill-in instructions, that reduces the time it takes for the "okay, so before the next appt..." section at the end of the appointment. It also means...
A) I don't forget to give important instructions (like NO ALCOHOL OR DRUGS)
B) There is a written record of my instructions, including med taper/titration
C) There is an opportunity for pt to ask questions about the details before leaving.
All nice to have should there ever be a legal question.
One other thing I've been advocating, but can't get the outpt clinic to agree to:
Assign appt times 15-20 min before the time I expect to meet the patient, e.g. if my calendar say the appt is 2pm, the patient's appt card says 1:45.
Most every place I've worked has about 20% no-show rate.
People can have trouble parking, busses run late, etc, so I don't want to cancel the appt until ~ 15 minutes after the time on the appt card. If we set the appt 15 min before, we can declare the pt "late" upon 15 min past the time on the card and not feel immoral. So, if the appt card says 1:45, and the pt arrives past 2pm, then it seems very reasonable for me to have moved onto something else, like seeing an "urgent care" walk-inpt who was waiting for a chance to be seen because of some emergent problem. This is very different than simply telling patients "please arrive 15 min before your scheduled appt" because that Never seems mandatory - even when I'm the patient at a doctor's office. But most everyone understands that if you arrive 15 min PAST the time on the appt card, that your are "LATE" and the doc may have had to move on to another patient, and your appt will be re-scheduled or you can wait to see if there is another no-show later in the day.
Another item, try to arrange to have phone/fax messages attached to the chart before being given to you. This may seem elementary, but some clinics don't customarily do this. If you get the messages and fax refill requests, etc. and then have to request the chart, it all takes so much longer. If office staff are saying that takes too much of their time, point out that this system allows them to take several messages to med rec's at once (like once every 2 hours), reducing the total time of running back and forth. If they insist that you see the message first and wait for you to request the chart, they will have to go to/from medical records many more times.
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I am not sure I am on board with the early appt idea either.
What does it really change? If they are supposed to be there at 2 and you have them scheduled at 1:45, won't you see them at 1:45 if there is nobody else around? So in effect, you are just moving all your appointment times 15 minutes earlier arent you? Then can't you just leave earlier? On the contrary, if you have it the other way, won't you just leave 15 minutes later and arrive 15 minutes later? No change in workflow, efficiency or the total time you work right?
Let me know if I am missing something.
What does it really change? If they are supposed to be there at 2 and you have them scheduled at 1:45, won't you see them at 1:45 if there is nobody else around? So in effect, you are just moving all your appointment times 15 minutes earlier arent you? Then can't you just leave earlier? On the contrary, if you have it the other way, won't you just leave 15 minutes later and arrive 15 minutes later? No change in workflow, efficiency or the total time you work right?
Let me know if I am missing something.
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The way I interpreted it, you would see the pt at 1:45 only if no one else is there, but typically you would be finishing up the patient you just saw. So instead of spending 15 minutes sitting around waiting for the patient to show up, you're spending that 15 minutes finishing up from the last patient like you would ordinarily do. That way would also ensure that if you're all caught up on charting (fat chance) you don't have to waste time waiting around for your last patient-- if they're not there by the time you finished the next-to-last patient (in this example, 2pm), you can leave "guilt-free" because the patient is actually late vs. just not showing up 15 mins early.
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Hand held dictaphone with USB connection. This way, post visit when things are still fresh you can hammer out your note far faster than you can type. Have some simple generic templates (macros) so you can hope from HPI, Psych ROS, etc. You can also train these things by typing in a word or phrase and then you correlate to it with your speech. For example BID or psedocyiesis. OVer time it also improves its effeciency to your voice.
It will also free you from check box medicine. It gets one back into having notes really reflecting the patient and not being constrained to what your 'boxes' leave you.
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I was never talking about leaving.
I'm talking about when you consider someone so late for their appt that you go on to see the next person who is waiting.
I our clinics, that would be seeing the next "urgent care" walk-in pt who is sitting in the waiting room hoping he can be seen if somebody no-shows. But it could be the next scheduled appt, if that person is already registered. If it results in me getting a little ahead, that's when I would handle phone call and pharmacy messages.
This system leaves no room for argument about whether the pt was late, because by the time it is 2pm, the pt is already 15 min "late" for the time printed on the card. At that point, there is no "my watch is slow" or "I was here on time but there was a line to register" or "I had to use the bathroom."
Patients interpret this very differently than if you simply "ask" them to show up 15 before their appt time.
