Note Anxiety: Writing notes in busy clinic is driving me crazy. Any recommendations?

[Nonphysiologic]

Hey guys,

In the private practice I joined we use OfficeAlly as our EMR. Furthermore we see a lot of PI and WC and these reports are done on a template form on Microsoft Word and then uploaded into the patients file in OfficeAlly.

The way we are doing it now is when a patient comes in I open their chart on OfficeAlly and then open documents. For follow ups it pops open their previous Word Document and I make the appropriate changes. For new patients I start a brand new template word document. For the non-PI or non-WC patients we just stay in the OfficeAlly environment and fill in the template in OfficeAlly itself.

I don't mind being busy but we are so incredibly busy and the notes are driving me nuts. I hate taking notes home or even spending an hour after work to finish my notes. I sort of have a system down and I use Dragon to dictate which helps. I do usually get my notes done before the day is over (maybe ill have to stay like 15 minutes extra) but it requires a lot of effort on my part and is starting to effect the time I spend with my patients and I dread going into work sometimes because sometimes well have like 4 patients all booked at one slot. God forbid the patient has a question or needs an explanation because that will hold up everything. And usually I am stressed in the back of my mind that I have to complete a note.

I may be idealistic but I don't like practicing this way. I know private practice pain is a numbers game but I am willing to take a pay cut to improve the quality of my work day and my interactions with my patients. Furthermore I don't like the idea of having a crappy note that's not completely accurate. I want to get rid of "charting anxiety" completely from my day. I know its part of the job to a certain extent but its starting to effect my interactions with patients which I don't like. I also am not in the position to request a decrease in patient volume. I have spoken with the office manager to stop double booking but the problem is there is a perceived high "no show" rate so I'm not sure if the double and triple booking will ever stop. I did request 15 min per follow up and 30 per new which is more than enough time.


Anyways I was curious to see what other people have done to help mitigate the stress of notes. Anyone have any OfficeAlly or PI/WC specific recommendations? Furthermore what are peoples experience using a scribe in such a high volume practice? How about virtual scribes? I know the other doctor working with me just hand writes everything and he created a system where he writes down key words for diagnosis, on their paper note and then hands them to a scribe at the end of the day and she just creates a note for him based on his key words. These notes however come off as very templated and not always the most accurate.

Let me know of your guys ideas and suggestions!

Thanks

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[Extralong]

Hire a PA/NP. Have an additional scribe/MA enter all the rooms with you and train them to know what to type up and/or what to write in the physical exam.

 

[Biohazard685]

If a reduction in volume is not feasible, then there is room for an MA to be trained that does a lot of the charting for you.

If you're not partner of your own clinic, then I think this might give you some leverage when it comes to negotiate contract/income.

Couple years ago I interviewed at a busy practice and the MA did all the notes and the physician just did a final read and dictated a plan of care.

On a side note, how is Office Ally?

 

[Nonphysiologic]

I’m not a huge fan of office ally. It’s ok. All I’ve ever used though was epic, cerner, and the GOAT imo: Athena


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[unchockey21]

I’ll second having an MA scribe. Love it. Let’s me focus on just being a doctor. We have physical exam sheets with common things I do and I’ll circle findings and they enter that in too. I just do a final double check and use Dragon to dictate part of the A/P. I’ll see 24-30 people per day. Last patient at 4:30, never left later than 5.

 

[Nonphysiologic]

I’ll second having an MA scribe. Love it. Let’s me focus on just being a doctor. We have physical exam sheets with common things I do and I’ll circle findings and they enter that in too. I just do a final double check and use Dragon to dictate part of the A/P. I’ll see 24-30 people per day. Last patient at 4:30, never left later than 5.

So does the MA come in with you? Or do you just write everything down and then hand them the sheet with everything circled in after the encounter?

 

[hyperalgesia]

I’m not a huge fan of office ally. It’s ok. All I’ve ever used though was epic, cerner, and the GOAT imo: Athena


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Thanks for sharing experience on Office Ally. I've only used their clearinghouse but was wondering about their EMR. It's weird that you can't create templates for those word docs... Do you actually upload them or just cut and paste? Seems like a real pain.

 

[Extralong]

So does the MA come in with you? Or do you just write everything down and then hand them the sheet with everything circled in after the encounter?

I initially did the circle thing, but once they were trained, they would come in the room with me.

 

[unchockey21]

So does the MA come in with you? Or do you just write everything down and then hand them the sheet with everything circled in after the encounter?

They come in the room with me. They’ll add any additional info I get from the history. The good ones can fill in the physical exam as I’m doing it but I circle the exam sheet and diagnosis codes so there’s no confusion. I have 2 MAs with me so while one is in the room with me, the other is bringing another patient back, checking vitals, prepopulating data into the note, bringing up any imaging and getting a brief history from the other patient.

 

[No Pain All gain]

We use ProScribe. It has been successful and I spend almost no time documenting. I can see plenty of patients.


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[jonnylingo]

EMR, trying to embrace the madness. No scribe but I'm using templates to help soften the blow of note writing.

This about sums it up...

 

[Ligament]

Get a scribe STAT! Best investment in quality of life you will make.
Post job listing at local universities where there are pre-meds. They will swarm you with applications. Being a scribe is apparently one of the very best feathers to put in one's medical school application nowadays.

I've had a pre-med scribe for about 5 years now, will never go back. Also there is a lot of joy in teaching and mentoring these young folk.

 

[emd123]

Hey guys,

In the private practice I joined we use OfficeAlly as our EMR. Furthermore we see a lot of PI and WC and these reports are done on a template form on Microsoft Word and then uploaded into the patients file in OfficeAlly.

The way we are doing it now is when a patient comes in I open their chart on OfficeAlly and then open documents. For follow ups it pops open their previous Word Document and I make the appropriate changes. For new patients I start a brand new template word document. For the non-PI or non-WC patients we just stay in the OfficeAlly environment and fill in the template in OfficeAlly itself.

I don't mind being busy but we are so incredibly busy and the notes are driving me nuts. I hate taking notes home or even spending an hour after work to finish my notes. I sort of have a system down and I use Dragon to dictate which helps. I do usually get my notes done before the day is over (maybe ill have to stay like 15 minutes extra) but it requires a lot of effort on my part and is starting to effect the time I spend with my patients and I dread going into work sometimes because sometimes well have like 4 patients all booked at one slot. God forbid the patient has a question or needs an explanation because that will hold up everything. And usually I am stressed in the back of my mind that I have to complete a note.

I may be idealistic but I don't like practicing this way. I know private practice pain is a numbers game but I am willing to take a pay cut to improve the quality of my work day and my interactions with my patients. Furthermore I don't like the idea of having a crappy note that's not completely accurate. I want to get rid of "charting anxiety" completely from my day. I know its part of the job to a certain extent but its starting to effect my interactions with patients which I don't like. I also am not in the position to request a decrease in patient volume. I have spoken with the office manager to stop double booking but the problem is there is a perceived high "no show" rate so I'm not sure if the double and triple booking will ever stop. I did request 15 min per follow up and 30 per new which is more than enough time.


Anyways I was curious to see what other people have done to help mitigate the stress of notes. Anyone have any OfficeAlly or PI/WC specific recommendations? Furthermore what are peoples experience using a scribe in such a high volume practice? How about virtual scribes? I know the other doctor working with me just hand writes everything and he created a system where he writes down key words for diagnosis, on their paper note and then hands them to a scribe at the end of the day and she just creates a note for him based on his key words. These notes however come off as very templated and not always the most accurate.

Let me know of your guys ideas and suggestions!

Thanks

Cheapest option: Get more efficient, write quicker and more concise notes.
2nd Cheapest option: Get a scribe.

I don't have a scribe because I'm pretty quick at doing notes and I feel my EMR is very good. But a couple people in my office have scribes and it seems to work for them. You only have to see 1 extra patient per day and the scribe pays for itself.

 

[Nonphysiologic]

What’s the typical rate for a scribe? I may just do that....


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[Extralong]

Have you also considered PA and/or NP students. They are actually pretty good too.

 

[clubdeac]

Nonphysiologic I feel your pain. Charting has become insane and it causes me significant anxiety as well. My mind during the entire visit is preoccupied with getting the damn note done. It's insane... I'm taking a new job soon and will be using epic. If anyone has any experience with this system and would like to share their thoughts or give advice I'm all ears!

 

[hyperalgesia]

Nonphysiologic I feel your pain. Charting has become insane and it causes me significant anxiety as well. My mind during the entire visit is preoccupied with getting the damn note done. It's insane... I'm taking a new job soon and will be using epic. If anyone has any experience with this system and would like to share their thoughts or give advice I'm all ears!

Good for you! Are you moving to a cool city?

I use Epic at several hospitals. I think it totally depends on how it's customized. I've never had much say in that so I'm constantly annoyed. You will probably have some control of it, so it might be good for you.

 

[Ducttape]

for me, the key was to make oodles of smartphrases, so i could make my own templates and customize my notes when i see fit.

 

[unchockey21]

for me, the key was to make oodles of smartphrases, so i could make my own templates and customize my notes when i see fit.

Agreed. Epic can be a little time consuming to set up initially but it pays off huge if you do it correctly from the get go.

 

[Jitter Bug]

Dumb question...but if the scribes are pre-med, aren't they in class? How can they be working a 9-5 in the office? Or is it several scribes cobbling together a full schedule?

 

[hyperalgesia]

Dumb question...but if the scribes are pre-med, aren't they in class? How can they be working a 9-5 in the office? Or is it several scribes cobbling together a full schedule?

My personal PCP always has at least 2 MAs that are pre-med. They actually already graduated and didn't get into med school their first try. Now they're working as MAs and some are taking night classes or doing research on the side.

It's win-win for all. These guys are really high quality and some only applied to one med school. Doc writes them a great rec letter and most of them have gotten into med school from what I've seen.

The disadvantage obviously is the turnover but like others have said, even that can be a good thing.

 

[Nonphysiologic]

So how do I go about finding a premed student? Is there some sort of HIPPA training they need to do? Also, how much should I pay them?

 

[Pain_doc]

There's a company called Scribe America in my area. As mentioned above, the most of the scribes have other aspirations and a couple that I know are heading to med school. One informed me that she is paid $12/hr and that the company charges $26/hr for her services.

 

[lonelobo]

There's a company called Scribe America in my area. As mentioned above, the most of the scribes have other aspirations and a couple that I know are heading to med school. One informed me that she is paid $12/hr and that the company charges $26/hr for her services.

Holy Batman what a ripoff

 

[bizdr]

I moonlighted during my fellowship in a place that seems similar to yours. I made $200/hr - but it was brutal! Even doing it one day a week was tough. Do you have any incentive based salary structure - so you can just make less $ and see less patients. If your life is going to be like this, you are gonna start hating medicine pretty quickly! Maybe you can offer to do EMG's or injections 2 days a week for a break? These will bring in more $ than the H&P's will.

 

[Nonphysiologic]

So I found a solution. I basically made a template which I circle findings and elements of HPI. I add some of my own notes. I have my MA's scan it to this scribe that works from home who writes it up and/or enters it into my EMR. Its been absolutely game changing.

Another question I have for everyone here is that do you guys have any templates I can use for the physical exam part that I can circle and check through on paper? I am still refining my forms so that it is easy to fill and easy for my scribe to understand and generate a form from.

Thanks

 

[lobelsteve]

old and basic.

 

[SSdoc33]

Nonphysiologic I feel your pain. Charting has become insane and it causes me significant anxiety as well. My mind during the entire visit is preoccupied with getting the damn note done. It's insane... I'm taking a new job soon and will be using epic. If anyone has any experience with this system and would like to share their thoughts or give advice I'm all ears!

EPIC is not your friend

 

[hyperalgesia]

So now the echo chamber admits that EHRs don't increase productivity but are instead a "burden" and a problem that needs to be solved. Enter the scribe.

Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience

 

[bronchospasm]

Hey guys,

In the private practice I joined we use OfficeAlly as our EMR. Furthermore we see a lot of PI and WC and these reports are done on a template form on Microsoft Word and then uploaded into the patients file in OfficeAlly.

The way we are doing it now is when a patient comes in I open their chart on OfficeAlly and then open documents. For follow ups it pops open their previous Word Document and I make the appropriate changes. For new patients I start a brand new template word document. For the non-PI or non-WC patients we just stay in the OfficeAlly environment and fill in the template in OfficeAlly itself.

I don't mind being busy but we are so incredibly busy and the notes are driving me nuts. I hate taking notes home or even spending an hour after work to finish my notes. I sort of have a system down and I use Dragon to dictate which helps. I do usually get my notes done before the day is over (maybe ill have to stay like 15 minutes extra) but it requires a lot of effort on my part and is starting to effect the time I spend with my patients and I dread going into work sometimes because sometimes well have like 4 patients all booked at one slot. God forbid the patient has a question or needs an explanation because that will hold up everything. And usually I am stressed in the back of my mind that I have to complete a note.

I may be idealistic but I don't like practicing this way. I know private practice pain is a numbers game but I am willing to take a pay cut to improve the quality of my work day and my interactions with my patients. Furthermore I don't like the idea of having a crappy note that's not completely accurate. I want to get rid of "charting anxiety" completely from my day. I know its part of the job to a certain extent but its starting to effect my interactions with patients which I don't like. I also am not in the position to request a decrease in patient volume. I have spoken with the office manager to stop double booking but the problem is there is a perceived high "no show" rate so I'm not sure if the double and triple booking will ever stop. I did request 15 min per follow up and 30 per new which is more than enough time.


Anyways I was curious to see what other people have done to help mitigate the stress of notes. Anyone have any OfficeAlly or PI/WC specific recommendations? Furthermore what are peoples experience using a scribe in such a high volume practice? How about virtual scribes? I know the other doctor working with me just hand writes everything and he created a system where he writes down key words for diagnosis, on their paper note and then hands them to a scribe at the end of the day and she just creates a note for him based on his key words. These notes however come off as very templated and not always the most accurate.

Let me know of your guys ideas and suggestions!

Thanks

Hire a transcriptionist who can post directly to EMR. It will cost you about $ 1200- 1500 a month. Pays for itself if you see one extra F/u patient / day.

My transcriptionist works as a remote live scribe. Notes are transcribed and put in EMR within 30 -60 minutes after dictation. 90 % of notes are completed by the end of the day. Typically it saves me about an 60-90 minutes every day and costs me about $ 50-75 per day.

This was suggested by someone here and has worked very well for me.

 

[peytonm]

I had EPIC in training and really liked using smartphrases ("dot phrases"). In private practice, I don't have EPIC. Have any of you found a way to use "dot phrases?" Like you are typing on your regular computer and call up your "normalexam" smartphrase, or "medial branch" smart phrase without having to go to a word document, search it, copy, and paste it?

Thanks!

And the key to EPIC is building great templates and smart phrases. You can basically build a "low back" template and tweak a few things. I also loved being able to copy and paste images (like of a scanned MRI or a radiology image representative of the problem).

 

[DOctorJay]

There are text expansion programs that can do what you’re looking for. Dragon or m*modal are very good now as long as you use a quality microphone.

I say cervical spine exam and get the whole normal exam that I add exceptions too which is quick.

Also have templates for all procedures with only a few dictated words.


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[drrosenrosen]

Seconded. I do the same thing with Dragon for exam and procedure notes. I have a few key phrases that I template in my HPI and A&P sections (e.g., "We reviewed risks, benefits and alternatives to interventional and noninterventional treatment modalities. I offered x and pt agreed to proceed with this plan of care.") But most of what I dictate in those sections is still original narrative.

 

[deleted472101]

Get a scribe. It is amazing.Scribeamerica. They hire and you pay a bill. I assume if you don’t like it then you just cancel services.

 

[ateria radicularis magna]

So I found a solution. I basically made a template which I circle findings and elements of HPI. I add some of my own notes. I have my MA's scan it to this scribe that works from home who writes it up and/or enters it into my EMR. Its been absolutely game changing.

Another question I have for everyone here is that do you guys have any templates I can use for the physical exam part that I can circle and check through on paper? I am still refining my forms so that it is easy to fill and easy for my scribe to understand and generate a form from.

Thanks

Does this present any hipaa issues? Does the home scribe work for a company? If so, and its been good, which company?

 

[callmeanesthesia]

Thinking of getting an MA to scribe for me - one MA would room patients and deal with phone calls and administrative work, while the other would follow me into rooms and enter the history and physical, then enter orders and schedule the patient for procedures while I dictated the assessment and plan, probably using Dragon or something similar, and closed the note. Currently I enter orders myself and our scheduler calls the patients later to schedule, and I dictate the full note which goes to our in-house transcriptionists. I then have to review and close it later, usually at night. Anyone use a set up like this? Any suggestions, recommendations, or words of caution?

 

[pastafan]

Thinking of getting an MA to scribe for me - one MA would room patients and deal with phone calls and administrative work, while the other would follow me into rooms and enter the history and physical, then enter orders and schedule the patient for procedures while I dictated the assessment and plan, probably using Dragon or something similar, and closed the note. Currently I enter orders myself and our scheduler calls the patients later to schedule, and I dictate the full note which goes to our in-house transcriptionists. I then have to review and close it later, usually at night. Anyone use a set up like this? Any suggestions, recommendations, or words of caution?

That is what I do but I use a transcriptionist instead of Dragon. Scribe=lifesaver for me as I can't type well and when I tried Dragon 5 years ago each note took forever to correct.

 

[callmeanesthesia]

That is what I do but I use a transcriptionist instead of Dragon. Scribe=lifesaver for me as I can't type well and when I tried Dragon 5 years ago each note took forever to correct.

Had Dragon in fellowship - it worked great. But I’m not sure if that’s because it was a ridiculously expensive fully EMR-integrated enterprise version. I have an old version on my current work computer, and it’s junk. It can’t even capitalize properly. We pay for our transcriptionists based on use, so I’m hoping I could save some money doing Dragon, and I’d also like to be able to close the note immediately. Our EMR is pretty slow, so it takes at least 3 minutes per chart to review and close it, which really adds up.

 

[Ducttape]

I don’t have a scribe right now but I imagine the beauty would be that you could have the chart open to review while the scribe is dictating separately.

 

[clubdeac]

Had a question regarding efficiency and thought it’d go on this thread. Do you guys remain standing in the room or do you sit down? I’ve been sitting down at the computer but find that it adds to my computer/documentation anxiety. The desk is a sit/stand desk. Thought maybe making it a standup desk might add to my efficiency and decrease my perceived stress

 

[DOctorJay]

I sit down and only use the computer to show images. On rare occasion I will place orders in the room. I do all my documentation out of the room in my own office.


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[lobelsteve]

I dictate. Sit on: rolling stool at computer to review records/notes/imaging with patient. Or sit on foot stool, or table, or one of 2 regular chairs in room. Always sit when talking to the patient. Poor form not to, makes the visit more personal. Connotes that you are listening.

 

[Ducttape]

sit down. there are studies that show that patients feel that the physician spends more time with them when the doctor is sitting.

for example: Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. - PubMed - NCBI

Patient Educ Couns. 2012 Feb;86(2):166-71. doi: 10.1016/j.pec.2011.05.024. Epub 2011 Jun 30.
Effect of sitting vs. standing on perception of provider time at bedside: a pilot study.
Swayden KJ1, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM.
Author information
Abstract
OBJECTIVE:
Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. This study provides empirical evidence for this perception.

METHODS:
We conducted a prospective, randomized, controlled study with 120 adult post-operative inpatients admitted for elective spine surgery. The actual lengths of the interactions were compared to patients' estimations of the time of those interactions.

RESULTS:
Patients perceived the provider as present at their bedside longer when he sat, even though the actual time the physician spent at the bedside did not change significantly whether he sat or stood. Patients with whom the physician sat reported a more positive interaction and a better understanding of their condition.

CONCLUSION:
Simply sitting instead of standing at a patient's bedside can have a significant impact on patient satisfaction, patient compliance, and provider-patient rapport, all of which are known factors in decreased litigation, decreased lengths of stay, decreased costs, and improved clinical outcomes.

PRACTICE IMPLICATIONS:
Any healthcare provider may have a positive effect on doctor-patient interaction by sitting as opposed to standing during a hospital follow-up visit.

 

[hyperalgesia]

I'm always sitting.

At my VA job, I usually type my note while talking to the pt. If I get any hint of discomfort or frustration, I stop and just listen intently. At my private private practice, I never type while talking to the pt, unless I'm bringing up an image.

The reason for the difference is the EMR. In PP, my EMR is only to help me help the pt. At the VA and in other hospitals, EMR is primarily for admin purposes.

 

[clubdeac]

Hmmm good to know... thanks for the input. Damn I was really thinking about standing. I got to get better, quicker documentation. There's just so damn much to document especially since I probably document level 4's 75% of the time, level 3's 20% and level 5's 5%

 

[Ducttape]

you have premade EMR templates?

if using something like Epic, there are tabs to pull over aspects of previous notes. i use that for ROS and PE, and then update them individually. the system does save them.

this also helps tremendously for those having had a prior injection. if i did the injection the same way as last time, it essentially is 3 mouse clicks with personalized updating of the H&P...

 

[callmeanesthesia]

Hmmm good to know... thanks for the input. Damn I was really thinking about standing. I got to get better, quicker documentation. There's just so damn much to document especially since I probably document level 4's 75% of the time, level 3's 20% and level 5's 5%

Does your MA/nurse enter the PFSH and ROS for you? Once I realized what I was actually doing in terms of medical complexity I document 90-95% level 5s for new patients, and a mostly even split between level 3 and 4 for fuv with the occasional level 2 or level 5.
I always sit but I do take too long in the room. Going to get a scribe so I can mostly eliminate time in the EMR in the room other than image review, and have them do the point and click of order entry for me.

 

[Extralong]

I like to sit if the patient is sitting. Generally I like to be eye level with them

 

[MD87]

Does your MA/nurse enter the PFSH and ROS for you? Once I realized what I was actually doing in terms of medical complexity I document 90-95% level 5s for new patients, and a mostly even split between level 3 and 4 for fuv with the occasional level 2 or level 5.
I always sit but I do take too long in the room. Going to get a scribe so I can mostly eliminate time in the EMR in the room other than image review, and have them do the point and click of order entry for me.

Can you give an example of a typical patient as far as medical diagnoses and what you are doing as far as treatment goes to bill a level 5? I work at a large organization with a few hundred physicians and I’ve been told by the billing department that billing a level 5 should be a rarity... my typical patient would be someone with obesity, lumbar radiculopathy, spondylosis. I maybe could add on a diagnosis of diabetes or chronic anticoagulation as another diagnosis. For the plan, the most I’m ever doing is prescribing PT, a med or 2 or 3, and either ordering an MRI or scheduling an injection. Even if I order and review an X-ray in the office myself and review MRI images and report myself I’m not sure that qualifies as level 5. I feel like I bill maybe 60/40 level 4s and 3s. What is everyone else doing?


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[pastafan]

Level 5 new office visit 99205 E/M coding, EM evaluation and management coding, e&m documentation, 99214, 99213