Increasing chart-reading efficiency

[SilverCat]

Hi,

I'm a fourth year, and work with EPIC at my school's hospital. My problem is that I work too slowly--my attending has me see 8-10 patients daily (no residents), and it takes me 2 hours to review their charts, and then 1 hour to pre-round. New patient charts take me 45 min to review, sometimes a hour if they are longer.

My question is--how do you speed up your chart-reading? We round at noon, so I have time, but I have no idea how I'll see 10 patients a day before 9 am as a resident.

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[Smurfette]

Hi,

I'm a fourth year, and work with EPIC at my school's hospital. My problem is that I work too slowly--my attending has me see 8-10 patients daily (no residents), and it takes me 2 hours to review their charts, and then 1 hour to pre-round. New patient charts take me 45 min to review, sometimes a hour if they are longer.

My question is--how do you speed up your chart-reading? We round at noon, so I have time, but I have no idea how I'll see 10 patients a day before 9 am as a resident.

--8-10 is a lot for a med4 to know well. 4-5 is more realistic. Depending on what field you go into, you may not be pre-rounding on that many a day, especially early on. Bear in mind that patients you admit yourself, you will know a lot better than those you didn't admit.
--Use the "time mark" feature so that you can easily see which notes and labs are new since your last review. This way you can avoid accidentally reading old notes or confusing new vs. old labs. I personally have my results set to display in reverse chronological order; it works better for me to identify the newest info and decreases the amount of scrolling I have to do.
--Most notes are full of autopopulated junk in the middle--look at the begining and end of a note for the pertinent stuff.
--If your version of epic has the button that will dither out the copied parts of the note and highlight the new stuff, use it; this way you won't be re-reading "old" information. You'll be shocked at how little "new" there is to read in a progress note.
--Skim non-physician notes---make sure no acute events were noted by nursing overnight and look at the bottom of PT/OT/etc. notes to see dispo recs.
--develop a system for looking up info. For instance: check vitals, I/Os, new labs, new imaging results, new notes, review meds. Then do it in the same order for each patient every time. It'll help prevent you from getting "lost" in a chart and will become automatic.

 

[Redpancreas]

Simple, stop checking your phone for Interview Invites 😛...

Totes JK. In all seriousness, this sounds like great practice and I'm jealous.

I'm at your level so take this with a grain of salt and also EPIC is not my primary EMR:
1. Get the VPL (Vitals+I/Os, Physicals, Labs)-1 min
2. Why are they here? Reduce it to the first sentence of a Step 2 CK question-2 min
3. Create a filter for the person for does the psychosocial eval on inpatients and use it to get their entire medical history -1 minute
4. Scan their most recent HPI and make a bullets in your HPI for everything that stands out (ex. s/p transplant, dialysis, etc.) 2-3 mins
5. Go down the rabbit hole only for the bullets in your HPI (find the tx note, CHF pt? look at the last cath, etc.) - 5 minutes

Efficiency takes practice and the more efficient we are now, the more time you'll have to be thorough when you're in charge. Hope this helps. Good luck!

 

[TypeADissection]

It's just repetition. As you keep doing it everyday you begin to figure out how to increase efficiency while maintaining accuracy. Having said that, I remember doing a lot of work as a med student on various services that I wouldn't even think of putting on my med students now. I mean this with no offense, but I truly do not count on med students on service for anything. I still want you guys to see patients and practice your physical exam skills and start forming plans, but I can get my own vitals, labs and write my own notes. So it's crazy to me that an attending would require a MS4 to see 8-10 patients per day. Having said that, this is great practice for you so take advantage of it.

 

[SilverCat]

Thanks for the advice! My attending is fairly lenient, and is an excellent teacher--probably the best I've had so far in terms of teaching. I think just finding all of the relevant past hisotyr--like reading prior hospitalization records--drains the most of my time.

 

[operaman]

This is a problem that will get better with time but you will find that some patients are so complex that they demand a lot of your time.

Overall, the efficiency comes less from your facility with the EMR and more from your medical knowledge and understanding of their diagnosis and its natural course. For example, when I look at my patients' charts, I'm going there with very specific things I'm looking for to answer a small handful of questions. These questions are different for each patient. The questions I ask nursing are very specific and again, different in some small ways for each patient. Contrast this with a student -- me as a student -- I would have a vague concept of their diagnosis and hospital course, but I went to the EMR to mine for every ounce of information I could find. Obviously this resulted in a great deal of wasted time, though also quite a bit of learning.

Reading outside records still kills my soul. Today it basically comes down to quickly skimming a bunch of auto-generated garbage to find something written by a human.

 

[Triple Cheeseburger]

Hi,

I'm a fourth year, and work with EPIC at my school's hospital. My problem is that I work too slowly--my attending has me see 8-10 patients daily (no residents), and it takes me 2 hours to review their charts, and then 1 hour to pre-round. New patient charts take me 45 min to review, sometimes a hour if they are longer.

My question is--how do you speed up your chart-reading? We round at noon, so I have time, but I have no idea how I'll see 10 patients a day before 9 am as a resident.

Admitting your own patients is key. If you are looking up new patients it will take time. Learning what and where it is found in the reports will help you save time. Practice Practice Practice. At the beginning of residency, you won't be expected to be ready to round on eight patients by 9:00 AM

 

[WhiteCoatWonder]

Admitting your own patients is key. If you are looking up new patients it will take time. Learning what and where it is found in the reports will help you save time. Practice Practice Practice. At the beginning of residency, you won't be expected to be ready to round on eight patients by 9:00 AM

not sure about this part.

cant say definitively, but on each inpatient rotation that ive been on as a student, interns on the team equally divided and were prepped to present all the patients...and definitely hours before 0930.

like if there were 20 patients on service + 2 interns, each intern had at least 6-8. im sure this stuff varies team to team but i think thats why many of them appreciated having students carry patients b/c the pressure was off of them to formally present (but they obvi still have to know overnight events, a.m. physical exam, plan, etc)

 

[BigRedBeta]

You're stuck as a Reporter in the RIME model. That's your issue,but you'll get better. Because you have to.

Ever wonder why your residents when you were a 3rd year were able to finish their H&P in about 10 minutes compared to your hour long interrogation? And theirs was still more complete (or at least more useful) than yours? It's because they know how to focus on what's relevant, what's going to matter for the patient and those around them.

There's a pervasive fear among most students that the only way they can excel is to know EVERYTHING. When you don't know the nuance to prioritize information, that's the most effective strategy, but as you get more experience, you'll find that you can be effective with far less effort. Focus on making that next step and learn the phrase "I don't know but I'll find out". There is literally nothing wrong with not knowing that the patient's second cousin had pancreatic cancer three years ago. As a peds ICU attending, I don't need to know birth history for my 9 year old patient, except to put it in my H&P so I can bill a higher level.