Time spent on documentation

[nm185]

Hi all! First off, just want to say thanks to the community here. I was helping my dad look into starting a private practice a while back, and I found a ton of helpful info on this forum. I have a lot of interest in psychiatry myself, so I've been lurking ever since.

How much time do you typically spend writing notes? What ways have you found to streamline the process? How much does it depend on inpatient/outpatient, policies/software at your workplace, insurance/private pay?

For some context, my dad is a psychiatrist, and I've often heard him complain about time spent documenting. I'm a software guy myself, so we've been batting around some ideas for software that could help with this issue. Before I get too invested, however, I want to see if this is a problem for anyone else, or if there's already something out there (better note templates, better EMR, etc.) that makes this a non-issue.

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[forchinet121]

I have my notes finished by the time the patient leaves the appointment so documentation is not an issue, your dad is probably not used to documenting while with the patient and that’s where the problem is. If I had to document after all my visits it would take me like an hour and I would hate my job

 

[comp1]

Yeah, I can't say this is a huge issue and it's even less of an issue now with telehealth.

 

[Sushirolls]

I over document.
I'm slow in part because of over documentation, and also avoidance behaviors with just getting it done. I document during encounters so typically most notes are mostly done and only require a few minutes to polish up before signing.

If I have more complex patients during day, who are follow ups, that will mean more documentation.

I use Luminello, and despite having much of my notes auto populated with the initial questionnaires filled in by patients, I still have a lot to document, and as such, I can only see about 2 people per day without feeling drained. Have I done more in the past and younger years, you bet but not going to anymore. The first follow up requires more documentation to get the basics of the note done. But follow up #2 onward, are ease to 'clone' with luminello that things really are quite fast. As I'm still building up the practice with new patients/consults, it is quite the time suck and I will document on in evenings or on weekends.

I keep telling myself one of these days, the practice will be almost entirely all establshed patients, and maybe 1 consult per week, and I'll have a better work life balance.

Any time I think of documenting less, something happens and re-enforces my gratitude for overdocumentation.

I've had days with 12 established follow ups, and I was done by 5PM with a single hour of admin time, but there might have been 1 no show.

Other times if I have 3-5 consults per week, I can get behind on notes, not done for a month, up to 20+ deep list. Takes a whole weekend to catch up. Its more rare to be done with all notes than it is to be behind for me.

 

[Wheatbread]

Dragon dictation has really reduced charting time. We use Epic so I pretty much copy forward previous notes and change subjective/pertinent MSE and plan changes. I can do a note in 2-3min tops.

 

[forchinet121]

I over document.
I'm slow in part because of over documentation, and also avoidance behaviors with just getting it done. I document during encounters so typically most notes are mostly done and only require a few minutes to polish up before signing.

If I have more complex patients during day, who are follow ups, that will mean more documentation.

I use Luminello, and despite having much of my notes auto populated with the initial questionnaires filled in by patients, I still have a lot to document, and as such, I can only see about 2 people per day without feeling drained. Have I done more in the past and younger years, you bet but not going to anymore. The first follow up requires more documentation to get the basics of the note done. But follow up #2 onward, are ease to 'clone' with luminello that things really are quite fast. As I'm still building up the practice with new patients/consults, it is quite the time suck and I will document on in evenings or on weekends.

I keep telling myself one of these days, the practice will be almost entirely all establshed patients, and maybe 1 consult per week, and I'll have a better work life balance.

Any time I think of documenting less, something happens and re-enforces my gratitude for overdocumentation.

I've had days with 12 established follow ups, and I was done by 5PM with a single hour of admin time, but there might have been 1 no show.

Other times if I have 3-5 consults per week, I can get behind on notes, not done for a month, up to 20+ deep list. Takes a whole weekend to catch up. Its more rare to be done with all notes than it is to be behind for me.

Can you give examples of what has happened where you were saved by over documentation

 

[FlowRate]

For the average telehealth patient, I write in sentence fragments during the visit to highlight the most important content. I go back and flesh it out into full sentences afterward. I typically spend 2-8 minutes after wrapping up with f/u patients cleaning up the note, refilling Rx, and updating the A+P and MSE (8 minutes is long end/complicated patients/need referral order or visit f/u info sent to RN etc.) I generally spend 10-25 minutes with the majority of f/u patients (30 min slots) so finish 99% of notes before the next patient or have just a few buttons to click before finishing by the time I start with the next patient.

With in person patients, I only document during the visit if they're a new patient, otherwise everything is documented after the visit for follow-ups. This is a small efficiency loss.

In the interest of cleaner documentation, all of the A+P is free text. If I was lazier I could pull in changed meds and visit diagnoses but I don't like the formatting of the smartlinks.

 

[TexasPhysician]

I document during appointments. I don’t spend time documenting after visits in 99% of visits. In the 1%, it’s an extra 5 minutes. There are dozens of great ways to minimize documentation depending on your system.

 

[Bartelby]

I agree with other responses. Getting documentation done during the visit (or being able to do so in a few minutes after) is crucial in outpatient practice. Most 30 min visits for me look like:

First 25 minutes: jot notes in the template as I talk with the patient, but only what really needs to be recorded (I'm still paying attention to the patient rather than playing stenographer). Add quick notes on other reviewed results and data.
Last 5 mins: visit is done. Finish MSE (this should usually be basic). One-paragraph assessment, update the copy/pasted plan for each problem. Take a brief breather before the next appointment starts.

Occasionally you have a couple mins of documentation, prescription, etc to do after. You can usually squeeze those into no-shows or shorter E&M only visits (generally if you aren't doing a therapy add on the visit can be pretty brief, for instance 10 mins face to face).

At the end of the day you are typically done, or at worst have 15 mins of note writing to wrap up.

For new patients review the chart for 15 mins before the appointment starts. Typically do this during no-show time or times when a visit wraps up early. Document succinct notes about all relevant info. Take notes as you gather the history. At the end of the visit, you generally only have an MSE + assessment and plan to finish. That should be do-able in 10 minutes, so try to make sure you leave that much time.

Rarely you deal with a very high risk situation, such a as not hospitalizing someone for good reasons but knowing there could be a bad outcome. In these cases (maybe 1 in 25-40 encounters) take the extra 15 minutes to explain your decision-making in depth. Those are the cases most likely to get scrutinized later.

Having all your notes and orders done as you go makes life much lower-stress with a stacked outpatient schedule.

 

[hamstergang]

I over document.
I'm slow in part because of over documentation, and also avoidance behaviors with just getting it done. I document during encounters so typically most notes are mostly done and only require a few minutes to polish up before signing.

If I have more complex patients during day, who are follow ups, that will mean more documentation.

I use Luminello, and despite having much of my notes auto populated with the initial questionnaires filled in by patients, I still have a lot to document, and as such, I can only see about 2 people per day without feeling drained. Have I done more in the past and younger years, you bet but not going to anymore. The first follow up requires more documentation to get the basics of the note done. But follow up #2 onward, are ease to 'clone' with luminello that things really are quite fast. As I'm still building up the practice with new patients/consults, it is quite the time suck and I will document on in evenings or on weekends.

I keep telling myself one of these days, the practice will be almost entirely all establshed patients, and maybe 1 consult per week, and I'll have a better work life balance.

Any time I think of documenting less, something happens and re-enforces my gratitude for overdocumentation.

I've had days with 12 established follow ups, and I was done by 5PM with a single hour of admin time, but there might have been 1 no show.

Other times if I have 3-5 consults per week, I can get behind on notes, not done for a month, up to 20+ deep list. Takes a whole weekend to catch up. Its more rare to be done with all notes than it is to be behind for me.

I relate to nearly all (though not entirely all) details of this.

 

[hebel]

How are you guys documenting during the visit, while keeping things "therapeutic?"

I need to start doing this, but often feel a little uncomfortable dividing my attention like that during a visit.

 

[FlowRate]

How are you guys documenting during the visit, while keeping things "therapeutic?"

I need to start doing this, but often feel a little uncomfortable dividing my attention like that during a visit.

I'm also really interested to hear from people who are 100% happy with their documentation done while seeing the patient (who don't typically add/edit afterward.)

As for my middle case, that's why my documentation during the visit is sentence fragments for the most important items. I find it really hard to talk and/or listen while writing full, high quality (grammar, punctuation, concision) sentences at the same time but pretty easy to type 5-10 words related to what we're discussing without missing a beat.

For new patients, a lot of my standard template is smartlists so really easy to handle those items during the visit and also they're all standard intake questions so I transition the appointment to an obviously more rote phase (patients aren't put off that I'm looking down more often than during HPI during this part.)

I don't complete MSE with the patient but my MSE is all smartlists as well so really quick to document unless there are multiple sections with atypical findings that aren't already in the smartlists.

I have a colleague whose f/u template is a bit fleshed out with typical components of the HPI/transition phrases as such:

@NAME@ presents today for follow-up after last being seen on ***. During the last visit, *** and a *** follow-up was recommended. *** No additional contacts occurred between scheduled visits. Current medication includes ***

@NAME@ arrived *** on time for the scheduled appointment and was accompanied by ***. @NAME@ was cooperative with individual interview. Since the last visit, @NAME@ reports that ***. @NAME@ denied suicidal ideation, intent or plan. Denied homicidal intent or plan. Denied auditory or visual hallucinations. Denied delusions.

Family is seen next and provides additional history. Family reports that @NAME@ has been ***

It's not my style, but an idea.

 

[Sushirolls]

How are you guys documenting during the visit, while keeping things "therapeutic?"

I need to start doing this, but often feel a little uncomfortable dividing my attention like that during a visit.

Lots of eye contact, 90% of time spent staring at patient, showing signs of active listening, or conversing.
Meanwhile, I'm typing simultaneously, and 10% less I look to computer to click to different spots to keep typing.
If I focus more attention on computer and clicking I tell the patient what I'm doing.
"I'm going to pull up the schedule now and see what we have available for 6 weeks out."
"I'm going to look at your prescriptions here and see when we last sent off that wellbutrin and when you might be do for refill"

I've noticed some patients seem to change their demeanor, best description I can give is like the couch of old analysts, sort of stare off at the artwork in the office and just openly talk. Rather than make eye contact in classic fashion to engage but openly stare off and purge all the latest stuff going on.

 

[comp1]

I don't understood why patients might think documenting the encounter in real time is somehow less therapeutic than just hoping the doctor remembers what was talked about. I can't see how it's more patient centered to take notes on paper than it is on a computer. I'm certainly quite comfortable with my own doctors charting during our sessions. Pure psychotherapy sessions might be different, but I've seen skilled therapists chart during those sessions and it wouldn't offend me to see my own therapist doing it.

 

[allantois]

 

[Merovinge]

I'm also really interested to hear from people who are 100% happy with their documentation done while seeing the patient (who don't typically add/edit afterward.)

As for my middle case, that's why my documentation during the visit is sentence fragments for the most important items. I find it really hard to talk and/or listen while writing full, high quality (grammar, punctuation, concision) sentences at the same time but pretty easy to type 5-10 words related to what we're discussing without missing a beat.

For new patients, a lot of my standard template is smartlists so really easy to handle those items during the visit and also they're all standard intake questions so I transition the appointment to an obviously more rote phase (patients aren't put off that I'm looking down more often than during HPI during this part.)

I don't complete MSE with the patient but my MSE is all smartlists as well so really quick to document unless there are multiple sections with atypical findings that aren't already in the smartlists.

I worked on a lot on these skills in my OP years of residency and fellowship. That, combined with my typing rate directly attributable to how fast one could get Diablo 2 trade offers in to maximize loot during my misspent youth, allows me to write the entirety of my subjective during the appointment. I click MSE boxes during the appointment as well and will free text the few pertinent words (I do CAP so less often do we have exciting MSE to comment on). I will prescribe any meds during the appointment and update the plan accordingly.

I do save every assessment box until after the patient leaves the room, this is the area that requires critical thinking for a few sentences and I never even attempt this while talking to patient's as I am not able to maintain eye contact and rapport.

I spend about 2 minutes in documentation after each appointment and I carve this time out even if the next patient is ready to go (baring some huge setback like needing to hospitalize a patient). I find it much more efficient than going back later to do the documentation.

I will say new patients need about 10 minutes to write up following the visit. I try to do this after the day is done but would be lying if I didn't have these evals wait a day or two to finish and be done during a free space in the day at times.

 

[Bartelby]

I'm also really interested to hear from people who are 100% happy with their documentation done while seeing the patient (who don't typically add/edit afterward.)

As for my middle case, that's why my documentation during the visit is sentence fragments for the most important items. I find it really hard to talk and/or listen while writing full, high quality (grammar, punctuation, concision) sentences at the same time but pretty easy to type 5-10 words related to what we're discussing without missing a beat.

I just sign my fragments .

To be fair, I do my MSE and assessment after the visit, so I am not fully 100% done while seeing the patient. Basically the subjective can read in the following style:

"Reports "so-so" mood. Frequently sad, did enjoy visit with son.
Sleeping 7h/nt, 2 waking 15 mins each
Tired through day
Appetite decreased
Concentration improved slightly since Wellbutrin increase
No SI

States had conflict again with ex-spouse. Experienced two days anxiety after. Working on emotion regulation with therapist."

I find I am able to type good-enough fragments while (as Sushi described) keeping 90%+ of my attention on the patient.

 

[splik]

For new consults, I write most of the note except the MSE, record review, assessment and recommendations during the visit. my notes tend to be quite detailed and include a good formulation. Because I find it tedious do complete the rest of the report, It can take me a while to get round to it and between 30 mins-1hr to finish. I charge for the time writing the note as well, bundled into the fee for the consultation.

for follow ups, I don't document during the session (I'm usually doing hour long therapy focused sessions) and it takes me 2 mins usually to write the note where I keep things to a minimum. The exception might be if there is a major change in clinical status (e.g. acute SI) or patient needs hospitalization then I will document a bit more in my risk assessment etc

 

[J ROD]

Our nursing staff starts our notes and fills in a basic subjective. EPIC makes things so easy can just copy paste and smartlink in a few minutes before I see the patient. I update a few things during appointment. Add a few sentences in subjective. Update plan and MSE. If more difficult patient, I may take couple minutes before seeing next patient. I run 20 min follow ups.

 

[SmallBird]

I never document in front of the patient - not saying that from a sanctimonious posture, I just don't. For inpatient I do all my notes at the end of the day in a chunk. For outpatient I try and finish 3 minutes before the end of a follow-up or 10 minutes before the end of an intake to get it done. I really like sitting comfortably closer to the patient without any screens, personally.

 

[WisNeuro]

I don't understood why patients might think documenting the encounter in real time is somehow less therapeutic than just hoping the doctor remembers what was talked about. I can't see how it's more patient centered to take notes on paper than it is on a computer. I'm certainly quite comfortable with my own doctors charting during our sessions. Pure psychotherapy sessions might be different, but I've seen skilled therapists chart during those sessions and it wouldn't offend me to see my own therapist doing it.

Don't know the literature on it, but anecdotally, charting during sessions was the #1 complaint from patients in the OP MH unit, back when I worked in the hospital, in the feedback forms. Wasn't even close between that and #2 of being the debacle that was central scheduling.

 

[hamstergang]

Don't know the literature on it, but anecdotally, charting during sessions was the #1 complaint from patients in the OP MH unit, back when I worked in the hospital, in the feedback forms. Wasn't even close between that and #2 of being the debacle that was central scheduling.

I searched the literature on this last year when my new boss questioned this practice. I recall finding that patients were generally ok with it so long as the doctors still made eye contact and seemed attentive. Though I don't recall the details.

 

[Stagg737]

Don't know the literature on it, but anecdotally, charting during sessions was the #1 complaint from patients in the OP MH unit, back when I worked in the hospital, in the feedback forms. Wasn't even close between that and #2 of being the debacle that was central scheduling.

I've also seen similar reports and I honestly think much less of the PCPs I've had who spent more time staring at the screen than actually interacting with me or my family members during the appointment. I get the our side too though and do it myself. Agree with the sentiments in Hamstergang's post, good eye contact and attentiveness mitigates some of the screen time. I also suck at documentation efficiency and just don't have the time to not document during an encounter, but my current outpt clinic is telehealth so kind of a moot point for me.

 

[calvnandhobbs68]

Don't know the literature on it, but anecdotally, charting during sessions was the #1 complaint from patients in the OP MH unit, back when I worked in the hospital, in the feedback forms. Wasn't even close between that and #2 of being the debacle that was central scheduling.

I've also seen similar reports and I honestly think much less of the PCPs I've had who spent more time staring at the screen than actually interacting with me or my family members during the appointment. I get the our side too though and do it myself. Agree with the sentiments in Hamstergang's post, good eye contact and attentiveness mitigates some of the screen time. I also suck at documentation efficiency and just don't have the time to not document during an encounter, but my current outpt clinic is telehealth so kind of a moot point for me.

Yeah I mean this may be the case but it's also just way less efficient on our end. I'd like to see the survey of patients if we gave them the option of spending the majority of a 25-30minute visit actually talking to us with some typing vs cutting them off at exactly 20 minutes so I can spend that last 10 minutes doing all the other stuff (sending meds, transferring my handwritten jots to the subjective cause I have a terrible memory and need to take some kind of notes during a visit, MSE, social hx, write the assessment/plan really quick).

Also I gotta say that I think this forum represents a slice of very efficient people overall lol. Almost all the attendings I knew would have days if not weeks worth of outpatient note backlogs to sign and I still know quite a few people like this. I get all my notes done same day generally that evening (I'll leave some new patients to the end of the week if I don't really want to do them that night) but I could definitely be more efficient...I also find in child it's tough to get a 30 min visit truly done in 20-25 minutes unless it's pretty straightforward as you generally need to spend 15 minutes at least with the kid alone (unless they're pretty young) and then another 10-15 minutes with the parent who now wants all their concerns addressed...

 

[WisNeuro]

Not knocking it per se, just reporting back what patients have thought. Moot point for me as I bill the time spent writing, and it's one of the higher
RVU producing codes we use.

 

[tr]

Don't know the literature on it, but anecdotally, charting during sessions was the #1 complaint from patients in the OP MH unit, back when I worked in the hospital, in the feedback forms. Wasn't even close between that and #2 of being the debacle that was central scheduling.

I'm aware of this but frankly I don't care. Whatever incrementally improved rapport I would achieve is not worth the waste of time and reduction in accuracy that would result from my trying to keep everything in my head and document after the fact.

Anecdotally I did have a patient ding me on my therapist eval for 'checking my phone' while in session (it was meds+therapy, I was doing the required two-factor authentication to write her controlled prescription). We had an extensive Changing the Focus type discussion about it which I think ultimately was quite therapeutic for both of us

 

[WisNeuro]

I'm aware of this but frankly I don't care. Whatever incrementally improved rapport I would achieve is not worth the waste of time and reduction in accuracy that would result from my trying to keep everything in my head and document after the fact.

Anecdotally I did have a patient ding me on my therapist eval for 'checking my phone' while in session (it was meds+therapy, I was doing the required two-factor authentication to write her controlled prescription). We had an extensive Changing the Focus type discussion about it which I think ultimately was quite therapeutic for both of us

I can see it for the vitals, but I have never had an issue keeping track of therapy content in 45 - 75 minute sessions and being able to chart in 5-10 mins after sessions using a template. To each their own, but I was trained in a context that you are fully focused on the patient in session.

 

[forchinet121]

I can see it for the vitals, but I have never had an issue keeping track of therapy content in 45 - 75 minute sessions and being able to chart in 5-10 mins after sessions using a template. To each their own, but I was trained in a context that you are fully focused on the patient in session.

I mean I think it’s pretty clear that not charting while with the patient is better for the patient I don’t think that’s debatable but whether that benefit is worth the significant burden placed on the provider is debatable

 

[WisNeuro]

I mean I think it’s pretty clear that not charting while with the patient is better for the patient I don’t think that’s debatable but whether that benefit is worth the significant burden placed on the provider is debatable

Mayhaps, but the "provider burden" is also pretty debatable depending on setting as it can be very minimal.

 

[Bartelby]

Mayhaps, but the "provider burden" is also pretty debatable depending on setting as it can be very minimal.

I tend to agree with 60 (or 90) minute therapy sessions. If I do take notes, it is generally only for the first few minutes (where the focus is more "E&M" than therapy). You can easily wrap up a 60-minute hour at the 50 minute mark and complete the note in the last 10 minutes with time to spare, and because most details of the therapy don't need to be recorded in the medical record it is easy to complete the note quickly from memory.

I think where things get trickier are intakes and back to back 30-minute appointments. In my experience that is where the trouble begins if you cannot chart as you go. Seeing, for example, 12 patients in a day and having 10 notes left to do at the end of the day gets difficult.

 

[Sushirolls]

Can you give examples of what has happened where you were saved by over documentation

I've had 3 encounters over the years, and just when I think maybe I'll turn to a minimalist charting style *bam* reinforcement of original charting behaviors.

I can only remember one. Years ago when still doing ECT. Documented all the existing physical concerns and cognitive concerns patient had in initial consult. Including level of comorbid Axis II, and mixed data for results, thorough pros/cons of the procedure. Post series patient started calling or letters or something about ECT causing XYZ and getting lawyers, etc. Reviewed notes and documentation of everything no merits to claims, everything patient asserted was present pre-morbid. Basically Axis II rearing head. Nothing manifested and if it had, I would simply said "look at the records, nothing more to say."

A lesser incident was patient made Schizophrenia diagnosis with, truly by the DSM nuances, this criteria, this criteria, etc. Family took patient to first break psychosis clinic **and told not schizophrenia nor psychosis** I had to review with family discrepancies happen in 2nd opinions and its up to them to consolidate, but I can't won't shan't change any documentation or diagnosis. My years of experience and the documentation both align and support this diagnosis. Made it easier to have that discussion with family - for me. Sadly, pt ended up streets, no meds, truly solidified the diagnosis in ensuing years.

Edit:
Just remembered a second one. Substance use. Patient stopped following up. Kept tight list of whose active whose not. Patient was formally closed. Patient, X many months later, died in circumstances ABC, and lawsuit popped up with other parties involved with demise and possibly could have been pulled into myself. Nothing happened or even record acquisition to my knowledge, but was potential. Notes reflected nothing of value IMO to feed a hungry lawyer looking for their easy scraps to feed on.

 

[WisNeuro]

I tend to agree with 60 (or 90) minute therapy sessions. If I do take notes, it is generally only for the first few minutes (where the focus is more "E&M" than therapy). You can easily wrap up a 60-minute hour at the 50 minute mark and complete the note in the last 10 minutes with time to spare, and because most details of the therapy don't need to be recorded in the medical record it is easy to complete the note quickly from memory.

I think where things get trickier are intakes and back to back 30-minute appointments. In my experience that is where the trouble begins if you cannot chart as you go. Seeing, for example, 12 patients in a day and having 10 notes left to do at the end of the day gets difficult.

Definitely agree about intakes, but I view those wholly separate in relation to therapy sessions. You should be documenting heavily in intake/evaluation sessions, but we also had those scheduled accordingly with appropriate time blocks.

 

[calvnandhobbs68]

I tend to agree with 60 (or 90) minute therapy sessions. If I do take notes, it is generally only for the first few minutes (where the focus is more "E&M" than therapy). You can easily wrap up a 60-minute hour at the 50 minute mark and complete the note in the last 10 minutes with time to spare, and because most details of the therapy don't need to be recorded in the medical record it is easy to complete the note quickly from memory.

I think where things get trickier are intakes and back to back 30-minute appointments. In my experience that is where the trouble begins if you cannot chart as you go. Seeing, for example, 12 patients in a day and having 10 notes left to do at the end of the day gets difficult.

Correct and honestly my notes contain way more information than most therapy notes I see. Which can absolutely make sense, since I have more information to review in a shorter amount of time.

My notes are also much much more likely to be used in a malpractice case than any therapy notes. So I need to be doing things like making sure I have an updated med list, making sure I'm commenting on suicidal/homicidal risk regularly, documenting about possible side effects from medications and if the patient is compliant with medications, various ROS stuff, substance use, etc.

This is literally no joke the meat of some of the therapy notes I see that pass for billing

MSE: stable
Lethality concerns: denies
Theraputic intervention utilized: CBT, supportive
Progress note: Client reported stable mood over last 2 weeks. Explored family dynamic and conflict with parents. Working on utilizing CBT and mindfulness skills effectively. Explored automatic thinking and engaged in exercise around this.
Followup plan: 2 weeks

 

[Sushirolls]

These days my over documenting is less for clinical and more for insurance.
Continuing to get those stupid letters from ChangeHealthcare trying to get people to down code.
All it takes is an insurance company to come in and say, "nah... that doesn't meet 99214" so now we will penalize, claw back this much money, and make your life hell in our preferred fashion of XYZ. Meanwhile, all of us here will clearly be in alignment, 'That duck quacks like a 99214.'
This is one of my fears in PP, insurance based, of an insurance company maliciously coming out for blood and knowing the difficulty I'd have in telling them to micturate off.
I'm doing better with shrugging off those fears but still they persist. On similar level of concerns we have in back of our minds with our patients A B & C who are little higher SI risk than others.

 

[tr]

I can see it for the vitals, but I have never had an issue keeping track of therapy content in 45 - 75 minute sessions and being able to chart in 5-10 mins after sessions using a template. To each their own, but I was trained in a context that you are fully focused on the patient in session.

Therapy notes I could probably chart post session without too much difficulty as mine are pretty brief. Homework completion review, 1-2 sentences about topics discussed/techniques used in session, HW for next time, done.

My med management notes are rather more detailed. In addition to occasional vitals like BP or scale weight, med management notes have much more detailed plans, usually at least 4-5 bullet points, and guaranteed I would forget to put a couple of them down if I had to do it after the fact. Not to mention the amount of visit time is shorter - I usually have 30 min for med mgmt and 60 for therapy - so it would be double the note burden for a day of care.

 

[clausewitz2]

Despite being shorter, I think a 30 minute E&M appointment can very easily and usually does generate more specific, detailed, potentially clinical relevant information than the traditional therapy hour. The specific details also matter a lot more - you often need to remember the precise number or the precise sequence of events, not remember the general sense of it or get it approximately right. Imagine being in intake/eval mode in every single appointment and you are closer to the mindset.

Also important to remember our caseloads are usually larger, so it is way easier to have a patient whose chart you open, stare at the name, and have no clue as to who this person is for a while. "Egg?"

 

[Candidate2017]

I've had 3 encounters over the years, and just when I think maybe I'll turn to a minimalist charting style *bam* reinforcement of original charting behaviors.

I can only remember one. Years ago when still doing ECT. Documented all the existing physical concerns and cognitive concerns patient had in initial consult. Including level of comorbid Axis II, and mixed data for results, thorough pros/cons of the procedure. Post series patient started calling or letters or something about ECT causing XYZ and getting lawyers, etc. Reviewed notes and documentation of everything no merits to claims, everything patient asserted was present pre-morbid. Basically Axis II rearing head. Nothing manifested and if it had, I would simply said "look at the records, nothing more to say."

A lesser incident was patient made Schizophrenia diagnosis with, truly by the DSM nuances, this criteria, this criteria, etc. Family took patient to first break psychosis clinic **and told not schizophrenia nor psychosis** I had to review with family discrepancies happen in 2nd opinions and its up to them to consolidate,

Edit:
Just remembered a second one. Substance use. Patient stopped following up. Kept tight list of whose active whose not. Patient was formally closed. Patient, X many months later, died in circumstances ABC, and lawsuit popped up with other parties involved with demise and possibly could have been pulled into myself. Nothing happened

1. Documenting history of physical and cognitive issues, and psychiatric/personality diagnoses, is legit helpful.
2. Parents disagreeing with first break psychosis is common, no biggie.
3. I'm a fan of actively closing people who don't follow up. But I'm not sure it's useful because even if I don't close them out, what is there to say if they fail to follow up at the appointed interval? They're noncompliant. As for substance patients (AUD severe and/or opioids), they have a high risk of death. The life span of someone who picks up an opioid habit is 5-6 years. We can only do what we can do.

This is literally no joke the meat of some of the therapy notes I see that pass for billing

MSE: stable
Lethality concerns: denies
Theraputic intervention utilized: CBT, supportive
Progress note: Client reported stable mood over last 2 weeks. Explored family dynamic and conflict with parents. Working on utilizing CBT and mindfulness skills effectively. Explored automatic thinking and engaged in exercise around this.
Followup plan: 2 weeks

I've seen some old psychiatrists document much shorter: "Doing ok. Everything same. Taking meds as prescribed, no side effects. No SI/HI. MSE... MDD, Anxiety. Prozac 40, Xanax 1 tid. RTC 12 wks."

As much as people like to rip on minimalist documentation, I'm starting to feel it is in most instances the light, the way, and the truth. Even if I were to enjoy evenings lounging by the fireplace and dictating lengthy notes/formulations, notes are to document patient's symptoms are controlled (or improved or worsened), danger assessment, we talked about... stuff, diagnoses, plan, and to jog my memory at the next visit.

Everything else is for legal purposes, allaying anxiety, and/or making us feel we're "good" psychiatrists. So, yeah maybe long notes are effective for decreasing anxiety and increasing self worth. But notes are probably not that effective against lawsuits, except in certain cirumstances. It's all part of the Russian roulette of practicing medicine. Good doctors can get sued and lose, while bad doctors may never get sued.

 

[Candidate2017]

Anecdotally I did have a patient ding me on my therapist eval for 'checking my phone' while in session (it was meds+therapy, I was doing the required two-factor authentication to write her controlled prescription). We had an extensive Changing the Focus type discussion about it which I think ultimately was quite therapeutic for both of us

Offer them the choice of either deep, meaningful eye contact, or benzos requiring two factor auth. My guess is they'd say, "Sure, play on your phone all day long!" I assume it's benzos because patients with actual ADHD are fiddling with their own phones and have a hard time noticing you're on your phone.

 

[Stagg737]

As much as people like to rip on minimalist documentation, I'm starting to feel it is in most instances the light, the way, and the truth. Even if I were to enjoy evenings lounging by the fireplace and dictating lengthy notes/formulations, notes are to document patient's symptoms are controlled (or improved or worsened), danger assessment, we talked about... stuff, diagnoses, plan, and to jog my memory at the next visit.

Everything else is for legal purposes, allaying anxiety, and/or making us feel we're "good" psychiatrists. So, yeah maybe long notes are effective for decreasing anxiety and increasing self worth. But notes are probably not that effective against lawsuits, except in certain cirumstances. It's all part of the Russian roulette of practicing medicine. Good doctors can get sued and lose, while bad doctors may never get sued.

Maybe it's because of the nature of the clinics I worked in during residency and my current outpt clinic, but some of the outpatient examples above are basically useless imo. If the patient has been chronically stable, sure. But if they require does adjustments or have new problems then that documentation is wasted. My issue with this is that if the patient moves to another psychiatrist, goes inpatient, insert any circumstance where another psychiatrist is seeing the patient, etc Idk what the eff was actually going on.

I don't need a novella, but imo there's a big difference between "depression worse today, poor sleep, feelings of hopelessness, passive SI" vs "patient reports worsening depression over the past 4-6 weeks after finding out their parent has cancer and will require significant care. Patient notes in this time they've had difficulties falling asleep d/t racing thoughts, have experienced significant fatigue, and hopelessness regarding situation. Denies active SI as well as thoughts of wanting to die, but would be okay falling asleep and not waking up."

One of those is actually helpful in guiding my treatment plan beyond "start an SSRI" while the other I may as well just be reading a bunch of check boxes...

 

[ObsequiousAplomb]

Maybe it's because of the nature of the clinics I worked in during residency and my current outpt clinic, but some of the outpatient examples above are basically useless imo. If the patient has been chronically stable, sure. But if they require does adjustments or have new problems then that documentation is wasted. My issue with this is that if the patient moves to another psychiatrist, goes inpatient, insert any circumstance where another psychiatrist is seeing the patient, etc Idk what the eff was actually going on.

I don't need a novella, but imo there's a big difference between "depression worse today, poor sleep, feelings of hopelessness, passive SI" vs "patient reports worsening depression over the past 4-6 weeks after finding out their parent has cancer and will require significant care. Patient notes in this time they've had difficulties falling asleep d/t racing thoughts, have experienced significant fatigue, and hopelessness regarding situation. Denies active SI as well as thoughts of wanting to die, but would be okay falling asleep and not waking up."

One of those is actually helpful in guiding my treatment plan beyond "start an SSRI" while the other I may as well just be reading a bunch of check boxes...

Even clearer and shorter:

"Found out father has cancer 6 weeks ago and will require significant care. Low mood since finding out, continuing to worsen. No anhedonia - still enjoying gardening. Trouble falling asleep - mind racing at night. Fatigued throughout day. Hopeless. Appetite preserved.
No active thoughts of death. 'it would be okay if I fell asleep and didn't wake up, though.'"

This doesn't require any editing, can be typed quickly while maintaining eye contact, and approaches both the order the patient likely gave the history and chronological order. I always find it challenging when notes reference things occurring in different sequences and by adopting my notes to occur in this order I've been more satisfied with their clarity and my ability to read them without any effort at all.

I also don't like when people are referred to as "patient" and (this is entirely distinct from your post as I'm aware you used no pronouns) I also don't like when pronouns are incongruent (frequently people say she and he for the same person, whether a typo or what, idk, but it's 50%+ of the notes I read) so I just structure everything to avoid that.

 

[calvnandhobbs68]

I also don't like when people are referred to as "patient" and I also don't like when pronouns are incongruent (frequently people say she and he for the same person, whether a typo or what, idk, but it's 50%+ of the notes I read) so I just structure everything to avoid that.

I mean not to get off on a tangent here but you do realize that avoids the whole issue of "he/she" pronouns by just referring to the patient as "patient' right?

 

[Merovinge]

I also don't like when people are referred to as "patient"

Can you explain why? I have such a hard time understanding why people suddenly dislike the millennia+ year old institution of doctor-patient relationships which seem to be under assault by mid levels, MBAers, and somehow some doctors as well?

 

[Stagg737]

Even clearer and shorter:

"Found out father has cancer 6 weeks ago and will require significant care. Low mood since finding out, continuing to worsen. No anhedonia - still enjoying gardening. Trouble falling asleep - mind racing at night. Fatigued throughout day. Hopeless. Appetite preserved.
No active thoughts of death. 'it would be okay if I fell asleep and didn't wake up, though.'"

This doesn't require any editing, can be typed quickly while maintaining eye contact, and approaches both the order the patient likely gave the history and chronological order. I always find it challenging when notes reference things occurring in different sequences and by adopting my notes to occur in this order I've been more satisfied with their clarity and my ability to read them without any effort at all.

I also don't like when people are referred to as "patient" and I also don't like when pronouns are incongruent (frequently people say she and he for the same person, whether a typo or what, idk, but it's 50%+ of the notes I read) so I just structure everything to avoid that.

And that note is fine, I just don't like the notes that are basically a one sentence summary and then a bunch of lines of basically checkboxes. I had one attending I worked with at a CMHC whose entire note would be "Denies SI/HI/AVH, continue medications" and that would be it. I inherited a couple of patients from him where that was every note for the past 2-3 years without anything auto-populated and I've seen other notes that were actually full notes that weren't much better.

 

[ObsequiousAplomb]

I mean not to get off on a tangent here but you do realize that avoids the whole issue of "he/she" pronouns by just referring to the patient as "patient' right?

I'm aware that they entirely avoided pronouns. I was just explaining why my default is to avoid it completely.

In reply to others, I avoid saying "patient" because it means "one who suffers." They aren't suffering when they're stable and in some cases they never feel as though they are suffering.

Really my avoidance grew out of annoyance from people calling them "pt" which made it hard to tell sometimes if the "pt" who said something was "physical therapy" or the "patient." There is also the grammatical issue of "the patient" versus "patient" and if I'm omitting one word for brevity I might as well omit both.

This also means I completely avoid "client" "customer" or whatever bull**** term the MBA wants me to say, which I find 30x as annoying as every sentence starting with "patient."

I know it's a very silly series of steps but it's what I write and the end result is it's quicker, imo clearer, and I avoid the whole pronoun debacle (which doesn't at all apply to his post, it was a tangential comment by me).

 

[allantois]

what about good ol’e “object”? Lol

 

[psychmd03]

When I did OP as a resident I did all documents and orders with patients in front of me. Learn how to type without looking at your computer and maintain good eye contact with patients. It will help if you can navigate your EMR without looking too. Use templates also that will drop in most of an MSE and skeleton of a note and fill in as the patient talks. When I went over meds I would be doing the orders checking if they need refills and which pharmacy as I navigate on the EMR. Everything was wrapped with the patient walking out the door. I even took my therapy notes on the computer because my handwriting is so bad and had a supervisor that really wasn't my biggest fan sign off on it because he felt the rapport was still solid with my patients so I do not think the people saying documenting with patients present will always be worse than not, have solid ground just likely need some more practice/better EMR.

Now I am purely inpatient and notes are mostly there for billing and getting my patient's days covered by the ridiculous insurance companies. I have a few that will deny with active si and no plan so the notes have to have certain levels of severity in until we are close to DC. I have a ton of templates built that help me populate sxs in various different ways of phrasing with a variety of MSEs so they can be plugged in in various combinations. And then a quick free text with some extra details in and notes takes less than a min easily.

 

[Merovinge]

I'm aware that they entirely avoided pronouns. I was just explaining why my default is to avoid it completely.

In reply to others, I avoid saying "patient" because it means "one who suffers." They aren't suffering when they're stable and in some cases they never feel as though they are suffering.

Really my avoidance grew out of annoyance from people calling them "pt" which made it hard to tell sometimes if the "pt" who said something was "physical therapy" or the "patient." There is also the grammatical issue of "the patient" versus "patient" and if I'm omitting one word for brevity I might as well omit both.

This also means I completely avoid "client" "customer" or whatever bull**** term the MBA wants me to say, which I find 30x as annoying as every sentence starting with "patient."

I know it's a very silly series of steps but it's what I write and the end result is it's quicker, imo clearer, and I avoid the whole pronoun debacle (which doesn't at all apply to his post, it was a tangential comment by me).

That's at least a novel and distinct answer from what I was expecting. Certainly is not convincing me to stop using patient but I can at least wrap my head around it.

I would point out that life is suffering and there is nothing wrong with that. There's much more wrong with the ways people go in an attempt to avoid suffering but actually causing dramatically more for themselves/people around them. You can call me a sufferer all you want, even though I live a better life than I estimate 99.99% of the world's population.

 

[nm185]

Thanks for all your responses. Sounds like investing time in better templates is the way to go. I'll admit that I was surprised at how documentation seems to be a non-issue for most people here, but like someone else said, this might be a more efficient group than the average. I know my dad has worked with several people who always had a huge backlog of notes to complete, and even some people that ended up getting pushed out because they could/would not keep up with it.

I think my dad's main problem right now is that he recently took over a lot of patients from a NP and there's been a mess to clean up. People come in for their 30 minute followup and he's trying to build rapport, do a full evaluation, and often change meds during those 30 minutes because the documentation is lacking and the diagnoses and meds are often wrong.

On another note, I'm also curious about how you structure your appointments. How much time do you spend in each "section" of the appointment (e.g. getting to know the patient, doing the evaluation, discussing diagnoses and treatment)? Or are appointments not really structured in that way?

 

[Candidate2017]

Maybe it's because of the nature of the clinics I worked in during residency and my current outpt clinic, but some of the outpatient examples above are basically useless imo. If the patient has been chronically stable, sure.

Yes, notes are shorter for chronic, stable patients.

I also trained where clinic attendings loved novels. Although it's important to start with lengthy notes then learn how to trim the fat, I suspect our attendings wanted long notes to allay their own anxieties and because they didn't have a grip on all the patients seen by all the residents in a day.

I don't need a novella, but imo there's a big difference between "depression worse today, poor sleep, feelings of hopelessness, passive SI" vs "patient reports worsening depression over the past 4-6 weeks after finding out their parent has cancer and will require significant care. Patient notes in this time they've had difficulties falling asleep d/t racing thoughts, have experienced significant fatigue, and hopelessness regarding situation. Denies active SI as well as thoughts of wanting to die, but would be okay falling asleep and not waking up.

The way your example is written, are you trying to convey your patient is worsening and could be drifting toward suicide in light of severe stressors of losing a parent? If they were to OD and fall asleep and not wake up, it wouldn't be hard to get a hired academic gunslinger to testify you missed all the red flags and should have done more.

On the other hand, are you trying to convey that the patient is experiencing normal sadness and anxiety related to an ailing parent? Like this:

Even clearer and shorter:

"Found out father has cancer 6 weeks ago and will require significant care. Low mood since finding out, continuing to worsen. No anhedonia - still enjoying gardening. Trouble falling asleep - mind racing at night. Fatigued throughout day. Hopeless. Appetite preserved.
No active thoughts of death. 'it would be okay if I fell asleep and didn't wake up, though.'"

 

[Candidate2017]

Even clearer and shorter:

"Found out father has cancer 6 weeks ago and will require significant care. Low mood since finding out, continuing to worsen. No anhedonia - still enjoying gardening. Trouble falling asleep - mind racing at night. Fatigued throughout day. Hopeless. Appetite preserved.
No active thoughts of death. 'it would be okay if I fell asleep and didn't wake up, though.'"

Even shorter:

Sad and anxious, affecting sleep initiation, and some fatigue, for past month due to parent's illness diagnosis. Passive thoughts of sleeping forever to escape parent's illness. Appetite ok. No anhedonia, carrying on hobbies. Denies SI/HI.

I like "appetite preserved". Interestingly, when patients report decreased/increased appetite, it actually needs to be >5% change in weight over a month. For the average 200 pound American person, that's 10 pounds. Also, when patients report depressed/low/sad mood, I feel it's important to figure out if it's actually most of the day, most days.