Practical Tips to Increase Visit Speed?

[JustPlainBill]

So I'm about 7.5 months into my intern year and am starting to get the hang of clinic. I want to start working on my speed per patient.

I try to write my notes while in the room in terms of the HPI/ROS and have a template for PE and software phrases that pull in current vitals and necessary labs.

Two places where I get slow--sometimes phenomenally so ---

1) Using an interpeter or interpreter phone
2) I still have to look up treatments for various problems -- usually stuff I don't do that often like H.Pylori treatment (after H.Pylori Ag positive).

Is that about par for the course or are there things I can do more efficiently? I've thought about doing my PE while interviewing the patient but that gets tricky when trying to use the interpreter phone AND trying to write the note.

Any hints/pointers? it's currently taking about 45 minutes for an uncomplicated lab follow up (from patient check in to patient check out) and about 1.5 hours for complicated patients. I'm scheduled for 6 q4H but actually see about 3-4.

BTW - I can't remember if I've asked this before, so if I have, sorry....

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[smq123]

So I'm about 7.5 months into my intern year and am starting to get the hang of clinic. I want to start working on my speed per patient.

I try to write my notes while in the room in terms of the HPI/ROS and have a template for PE and software phrases that pull in current vitals and necessary labs.

Two places where I get slow--sometimes phenomenally so ---

1) Using an interpeter or interpreter phone
2) I still have to look up treatments for various problems -- usually stuff I don't do that often like H.Pylori treatment (after H.Pylori Ag positive).

Is that about par for the course or are there things I can do more efficiently? I've thought about doing my PE while interviewing the patient but that gets tricky when trying to use the interpreter phone AND trying to write the note.

Any hints/pointers? it's currently taking about 45 minutes for an uncomplicated lab follow up (from patient check in to patient check out) and about 1.5 hours for complicated patients. I'm scheduled for 6 q4H but actually see about 3-4.

BTW - I can't remember if I've asked this before, so if I have, sorry....

* I often do not do my notes while in the room. I feel that that often slows me down, particularly for complicated patients. After 6 months of intern year, my memory had gotten good enough that I can remember the details for later. I will sometimes do the HPI and PE on our EMR while waiting for the next patient.

* Even if I get bogged down in one visit (a complicated patient or a non-English speaking patient), I'm usually fast enough that I can make up for lost time with the next patient. So, on balance, I end on time. Usually.

* I choose one or two reliable sources for treatments. I know them inside and out and know how to quickly find the info I need in them. This minimizes the amount of time that you spend looking.

 

[EdibleEgg]

1) Begin setting an agenda as soon as you enter the room. As an intern, most patients are going to be new to you. So don't get frustrated that you are not seeing 30 a day, but you can't solve all of the world's problems in a single visit.
Try not to have more than three things on that agenda.

2) Do your best to have the note done before you leave the room. I know that's tough to do as an intern. You often don't have your plan well formulated when you leave the room, but develop good habits early. You will never know more about the patient that when you are in the room. Also, when you are seeing 30 a day, you will be spend your nights catching up on notes...

3) You are always going to see things you have to look up, but the most common 20 diagnoses are going to make up the vast majority of your office visits. Do some reading a make a cheat sheet, or find an easily available reference that you know well.

4) I don't know how to help with the interpreter, but what do you do for 45 minutes in a lab follow up?

 

[lowbudget]

Totally agree with EE that you want to get as much of your note done before you leave the room, because it is a good habit. Once your volume picks up you will drown in charts if you wait to leave the room to start it.

For me, I can touch type so I do my HPI, PMH, FH-SH, and ROS on a laptop. I can't record while I'm doing my exam, so I skip it, write my A&P which is most important, generate my scripts, labs, referrals, get the patient out then write in my exam before I sign off the chart.

For those of you who don't do your charts during the visit, I recommend doing your ROS the same time you do your exam. I have a hard time doing this because I can't focus on my exam and talk and listen at the same time. But it is something you can try.

Ultimately, in my opinion, you will gain the most speed the "smarter" you are. In my opinion, the decision-making (formulating you A&P) takes the longest time. If a case reveals itself early in the history and you have already made your decision, the rest of the exam flies by because you focus, but I've found out that if I'm stumped, I ask a lot of questions, look everywhere on the body, and mull over my next steps and order a bunch of stuff.

So, logically, the best way to save time is to not get stump! Well... that means you need to study. And experience. But studying is the key because your mind can move in lightning nanoseconds while looking things up take up time.

If you study and are able to "connect the dots" with ease you can handle the 30 patients a day with 3 problems and 2 additional oh by the ways because sometimes all these complaintss are related. (And sometimes not... welcome to family medicine). This is our challenge and this is what we strive to be good at.

If you find yourself going way too fast, I challenge you to be more comprehensive and look for other issues the patient might have to address. You can bill a higher level and its good for the patient if you're in a family medicine setting.

My advise for an intern looking to go fast on a pure time motion standpoint is to minimize your in-and-out of the room. I've found out the more I leave the room and come back, the more oh by the ways I get.

 

[JustPlainBill]

1) Begin setting an agenda as soon as you enter the room. As an intern, most patients are going to be new to you. So don't get frustrated that you are not seeing 30 a day, but you can't solve all of the world's problems in a single visit.
Try not to have more than three things on that agenda.

2) Do your best to have the note done before you leave the room. I know that's tough to do as an intern. You often don't have your plan well formulated when you leave the room, but develop good habits early. You will never know more about the patient that when you are in the room. Also, when you are seeing 30 a day, you will be spend your nights catching up on notes...

3) You are always going to see things you have to look up, but the most common 20 diagnoses are going to make up the vast majority of your office visits. Do some reading a make a cheat sheet, or find an easily available reference that you know well.

4) I don't know how to help with the interpreter, but what do you do for 45 minutes in a lab follow up?

As far as lab f/u taking 45 mins -- I'm still at the stage where I'm trying to think of things my attending may ask me once I leave the room to present. So I do 2 ROS and sometimes that opens a can of worms. Yesterday was a lot of lab f/u and most of them were done in 35 minutes from the time they checked in to the time they left. But the attending I had was a no-BS, get the job done and move on type of attending, not a pimp the intern because I can type of attending.

thanks for the advice - it's coming together but slowly.

 

[EdibleEgg]

As far as lab f/u taking 45 mins -- I'm still at the stage where I'm trying to think of things my attending may ask me once I leave the room to present. So I do 2 ROS and sometimes that opens a can of worms. Yesterday was a lot of lab f/u and most of them were done in 35 minutes from the time they checked in to the time they left. But the attending I had was a no-BS, get the job done and move on type of attending, not a pimp the intern because I can type of attending.

thanks for the advice - it's coming together but slowly.

You make a good point. Getting to know individual attendings and their expectations will help with speed. Your review of systems should be focused. Going through the ROS twice with the typical resident patient with SLS is a dangerous game.

Good luck.