So, let's talk about documentation efficiency for new attendings

D

da8s0859q

I'm a "new guy" out of residency. Much prefer being an attending. Imagine that.

I'm very careful and particular about my notes. I'm sure the residents and midlevels at my hospital roll their eyes a little, but hey, they're my notes (or attestations), and they exist for some good reasons.

We use Epic.

I'm debating what is the most efficient way to handle documentation when you're a little bit of a detailed documenter. What I did for residency was just do the HPI, ROS, and PE after seeing the patient. I would pend the note and leave the MDM, EKG interpretations, so forth, to the end of shift (or do it in a five minute break if there ever was one).

I don't use the click-through HPIs in Epic. I free-text (dictate) all of it, list pertinent +/- in the HPI, and use a disclaimer for the ROS. I use macro-based exams that are quick and which I constantly refine.

What would be better? In a place where 3-4 pph happens routinely, is it better to dictate MDM in bits with timestamps as the ED course progresses and "touch" the MDM that many more times for the sake of not having to do so many notes after the fact, but at the cost of picking up a few more charts?

For resident and midlevel charts, better to have them use the "Share" function in Epic so I can addend their notes in real-time? Do a separate mini-note?

Something else?

I'm finding that notes to my standards are taking entirely too much time.
 

DissocativFugue

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Get a scribe.
Agreed, at 3-4 pph your choices are to either slow down and lose RVUs/back up the department, chart for 2-3 hours after shift, or hire a scribe.

On a per hour basis, a scribe is the most cost effective way to boost your productivity and cut down on the needed AA meetings after hellish shifts.


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Angry Birds

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Scribes are awesome. It makes the shift much more enjoyable.
 
OP
D

da8s0859q

We use scribes for some shifts, but they've been very... hit or miss despite what I ask them to do. Saying things I didn't say, or not saying things I explicitly asked them to include. Or saying things I asked them to not say because they aren't true. No, the kid is not f*cking lethargic. Yes, I considered PE and didn't dimer or CT because of __. Maybe I just need to be more direct.

Aside from that, any other suggestions or tips that you guys found useful coming out to cut down on charting time and still having a worthwhile note?
 

namethatsmell

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Sep 16, 2010
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Also a new attending and agree documentation has been more time consuming than I expected.

I have a google doc with a bunch of random "I don't think pt has __. because of X, Y, Z" and some other things like my standard AMA line because my system doesn't do macros well. I can copy/paste so saves a little time.

Also have scribes and they range from decent to super helpful.
 

KinesiologyNerd

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We use scribes for some shifts, but they've been very... hit or miss despite what I ask them to do. Saying things I didn't say, or not saying things I explicitly asked them to include. Or saying things I asked them to not say because they aren't true. No, the kid is not f*cking lethargic. Yes, I considered PE and didn't dimer or CT because of __. Maybe I just need to be more direct.

Aside from that, any other suggestions or tips that you guys found useful coming out to cut down on charting time and still having a worthwhile note?
It will help a lot once you have better rapport with the scribes and they know what you like. With that said there are also just a lot of scribes who are not good.

Edit: Also, when I scribbled some of the attendings had the scribes do the box checking and they would do narratives (at least when it needed nuance).
 

BAM!

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Don't leave all your MDM charting to the end. you will guaranteed be spending a LOT of time after your shift if you do this.

This is pretty common. I went through it too.

Some tips I found helpful:
Use macros and preset smart phrases
use scribes (if'they are good)
use dragon for long MDM's which need to be personalized
ABC's of Emergency Medicine = Always Be Charting.
Try to chart in the room if applicable (makes the patient feel like you're spending more time with them too).
figure out when the other doctors in your group STOP seeing patients. you may find it's 1.5 hrs prior to the end of the shift.

good luck! it will get better.
 

pencilcase

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Scribes do vary in skill. I had one great one that everyone loved but there was a policy that you can't request any scribe. The others were not good, oftentimes only using clickboxes for the HPI and leaving basically the whole story out. I like my HPI to have pertinent positives and negative like RFs for CAD or PEs even if they are also in the ROS. Lot of times, scribe notes were hard for me to follow. In the end, I would spend a lot of time editing the scribe notes even when I had spent time coaching them on what to add and what to not add (they tend to use the same ROS and Physical exam templates over and over and this leads to marking things that are not pertinent to the encounter or were not done).

In the end, I decided to just see my own patients and do my own charting with no scribes. I am at >2patients per hour with 2 hours charting at home which is worth it for me. I am kinda intense on charting and like to know exactly what I put in there. Some of it has to do with my residency training where the MDMs usually included why some test was not done or no repeat trop etc. Basically speaking to the lawyer incase of malpractice or your co-docs if they see the patient subsequently.

I have noticed the other attendings who are seeing 30 patients a shift (>2.5 per hour) just sign the note written by the scribe without even reading the content :uhno:I also found myself babysitting the scribes and being less efficient. I work better without scribes but I did try them just because everyone talks so highly about scribes.

My suggestion is; If you have cerner make a macro for ROS and Physical exam. For instance, the physical should basically be a visual exam of the patient i.e what the exam would be based on just observing the pt e.g., no acute distress, normocephalic, neckk normal ROM, RRR, normal respiratory effort, abdomen non distended, skin- no rash, msk- normal ROM, psych- normal judgement, near- AAOX4 etc


Then use this same macro for all patients and then just add things you did that are specific to that encounter, e.g., if you listened to the lungs and they were clear, now you can just click CTAB on the prepopulated macro. Then hit discharge/admit and condition. Only add in the MDM, life threatening thing you had to rule out and follow up. Those usually hit the coding stuff. Unfortunately with corner you do have to do the click boxes for the HPI if you want to be stellar in billing. Just add a three sentences HPI under the click boxes to remind yourself what the pt said was the reason for their visit incase you have to defend the case in the future- you want an HPI with enough info to conjure your memory. Click boxes alone won't be enough

Hope that helps somewhat...btw epic is better than cerner for charting, e.g. the drawings on cerner are ******ed and hard to work with...but you just gotta work with what you got.

Also don't talk too much with the nurses, just enough to be approachable. You need to be charting during the shift like it's nobody's business. The more you chart at work, the less you have to chart at home.
 

emergentmd

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I work in places with a scribe and ones without.

Scribes are hit/miss and if I read all of their charts and correct it, I would be better off doing it myself. But I am not stickler with notes and so I don't even read it unless its a old pt or concerning complaint.

In my nonscribe job, I chart to tell my story and what their disposition is. Most discharge CP sounds the same, admitted CP sounds the same. Once you get a hang of story telling, its not bad. I can see 2.5pt/hr, chart myself, and leave about 30 min after the new guy comes in typically. Some see 2/hr and still say back 2hrs to clean up/chart.

I am sure their charts are more accurate but mine are more legally defensible.

Plus over the past 15 yrs of working, if I stayed back an extra hour to chart, that comes out to 2700 hours. That comes out to close to 1.5 yrs of full time work or about 600K to me. This doesn't include the mental aggravation, missing out on my kids, family time, intangible benefits.

New and docs are amazed that i can see 25 pts/shift and walk out the door when they come in. Knock on wood, my charts usually reads the best of most doctors and always legally defensible.
 
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I work in places with a scribe and ones without.

Scribes are hit/miss and if I read all of their charts and correct it, I would be better off doing it myself. But I am not stickler with notes and so I don't even read it unless its a old pt or concerning complaint.

In my nonscribe job, I chart to tell my story and what their disposition is. Most discharge CP sounds the same, admitted CP sounds the same. Once you get a hang of story telling, its not bad. I can see 2.5pt/hr, chart myself, and leave about 30 min after the new guy comes in typically. Some see 2/hr and still say back 2hrs to clean up/chart.

I am sure their charts are more accurate but mine are more legally defensible.

Plus over the past 15 yrs of working, if I stayed back an extra hour to chart, that comes out to 2700 hours. That comes out to close to 1.5 yrs of full time work or about 600K to me. This doesn't include the mental aggravation, missing out on my kids, family time, intangible benefits.

New and docs are amazed that i can see 25 pts/shift and walk out the door when they come in. Knock on wood, my charts usually reads the best of most doctors and always legally defensible.
Is it safe to say that EM notes are really centered around the CC, HPI, PMH, and ROS and Physical Exam??
 
OP
D

da8s0859q

I work in places with a scribe and ones without.

Scribes are hit/miss and if I read all of their charts and correct it, I would be better off doing it myself. But I am not stickler with notes and so I don't even read it unless its a old pt or concerning complaint.

In my nonscribe job, I chart to tell my story and what their disposition is. Most discharge CP sounds the same, admitted CP sounds the same. Once you get a hang of story telling, its not bad. I can see 2.5pt/hr, chart myself, and leave about 30 min after the new guy comes in typically. Some see 2/hr and still say back 2hrs to clean up/chart.

I am sure their charts are more accurate but mine are more legally defensible.

Plus over the past 15 yrs of working, if I stayed back an extra hour to chart, that comes out to 2700 hours. That comes out to close to 1.5 yrs of full time work or about 600K to me. This doesn't include the mental aggravation, missing out on my kids, family time, intangible benefits.

New and docs are amazed that i can see 25 pts/shift and walk out the door when they come in. Knock on wood, my charts usually reads the best of most doctors and always legally defensible.
Curious, what makes yours legally stronger versus the more verbose MDMs of your colleagues?

I've been fighting with either doing the MDM on dispo (keeps me from seeing another patient that second during shift) or after shift, but the former seems to make me pare down what I say.
 

emergentmd

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Curious, what makes yours legally stronger versus the more verbose MDMs of your colleagues?

I've been fighting with either doing the MDM on dispo (keeps me from seeing another patient that second during shift) or after shift, but the former seems to make me pare down what I say.

I always chart only when there are no other patients to be seen. All patients have a complaint and a disposition. My charting neatly makes my point without any ambiguity.

Take chest pain. Most has a 10/10 pain. Most have a heavy quality that radiates. But we all know most young CP are crap. So my charting will always paint an Atypical story eventhough their history makes it seem they are having the classic MI.

I think a short and clear story that takes the reader down the path of your disposition is what is important. No need to add onto you HPI where you can't defend your disposition.

I have read too many charts where people are discharged but if you read the chart, you think they are about to die. Don't be this charter.
 
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The White Coat Investor

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I type the HPI, MDM, and discharge instructions. I use checkboxes for the other stuff and don't worry nearly as much about them. Lots of people at my shop using dragon now and love it, so if you're a slow typer look into that.

We have a new doc, overly slow, who is a very thorough charter. It's a problem. Don't be a problem. Chart what you need to, but don't overchart.
 
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You can use "dot phrases" (text expansion) regardless of what EMR your place uses. You just need a text expansion program. These vary a lot in functionality and can do amazing things for you - including create drop downs/open websites, even calcualte things (clinical decision scores).

I am a huge fan of templates. I think they help me think through common differentials and recommend doses for medications etc in addition to helping making notes faster. The biggest issue is you have to be very cognizant not to include information that isn't true for hte specific patient.

I use a program called Breevy which is very user friendly as my text expander but there are many out there. http://www.16software.com/breevy/ If you use this program make sure you change the settings so it "pop"s the words at once instead of "typing" it out - which is really annoying , particularly in cerner for some reason.

Also not a fan of scribes for the reasons others have said - personally think it's only helpful if you are a slow typist or you don't actually read the notes.
 

EctopicFetus

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We use scribes for some shifts, but they've been very... hit or miss despite what I ask them to do. Saying things I didn't say, or not saying things I explicitly asked them to include. Or saying things I asked them to not say because they aren't true. No, the kid is not f*cking lethargic. Yes, I considered PE and didn't dimer or CT because of __. Maybe I just need to be more direct.

Aside from that, any other suggestions or tips that you guys found useful coming out to cut down on charting time and still having a worthwhile note?
Yours need better training. Sometimes they dont know cause in the pan positive ROS patient who freaking knows what to write. The doc does becasue we know which squirrel is gonna try to find which nut. They have no idea.
 
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