Time spent on documentation

[Stagg737]

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.

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:

I've had similar attendings and while I appreciate the details as an attending now, I don't expect a novel. As I said, I wouldn't have any issues with OA's example as it conveys some thought as to context of symptoms. But without context we may as well-just be receptionists checking boxes. I could shorten my example further to say:

"worsening depression over the past 4-6 weeks, patient attributes this to parent's declining health. Feelings of hopelessness regarding situation. Now having problems initiating sleep d/t racing thoughts, significant fatigue. Reports some apathy toward living but denies thoughts of actively harming or killing self."

To the bolded, I'm trying to put the patient's "SI" into context. Just saying "passive SI" is kind of like just saying "depressed". If someone just wants to convey that SI isn't active and that patient doesn't have thoughts of directly killing themselves, that's fine. It doesn't give me any context of their thoughts though. Are these thoughts of wishing they were dead? Wishing they just didn't exist? Apathy towards life? Those are often not equal scenarios and speak to different constructs of depression which may lend themselves towards specific treatments.

I didn't really talk about how I'd approach that treatment either, as if I felt they were "drifting toward suicide" we'd be directly talking about that and it would be discussed in the assessment/plan. I was just talking about how I'd document the HPI so others could understand the situation a little better than "depressed patient meeting MDD criteria". For aspects like mania or disorganized psychosis those details are less relevant, but to anxiety and depression where the etiology of that particular symptom can vary so significantly that context is important. I'm also not too concerned about someone testifying against me, my OCPD traits come out pretty aggressively in my assessment and plan portions of patients that are actual risk concerns, lol.

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[tr]

Sorry I can't stand long resident notes. I feel like half the time the information required to inform the plan isn't there, and instead there is this pile of useless boilerplate CYA verbiage describing ten different ways the patient is not suicidal. Then on the off chance that the necessary information actually is there, I have to skim through all the verbiage to find it.

I am guessing somebody must be actively teaching them this because all the trainees do it. I'd like to find out who it is so I can pour glue in their keyboard.

 

[G Sheb]

Sorry I can't stand long resident notes. I feel like half the time the information required to inform the plan isn't there, and instead there is this pile of useless boilerplate CYA verbiage describing ten different ways the patient is not suicidal. Then on the off chance that the necessary information actually is there, I have to skim through all the verbiage to find it.

I am guessing somebody must be actively teaching them this because all the trainees do it. I'd like to find out who it is so I can pour glue in their keyboard.

Oh gosh, don't get me started on those medical student notes either. LOL.
Part of it is that people get better in identifying critical information as they progress through the training and so there's less useless verbiage, but writing a compact, organized note is really important. Nobody wants to read pages of stuff.
The best notes are also the ones that can give you a feel of what it's like to be with the patient in the room.

My other pet peeve is those who confuse the MSE with the HPI or subjective part.
MSE is in the MSE. It's NOT in what the patient is reporting. You should not tell me the patient was organized, bla bla bla in the same paragraph where you report what they say. It does tell me something about people's ability to critically evaluate data when they lump it together.
You should put it all together in your assessment.

So much of the documentation is CYA bs instead of actual clinical evaluation and formulation.

I also do not like to document electronically while talking to patients. Prefer to sit and have full on eye contact, and I can take notes with a pen and paper. When I was in therapy, I did find the typing sound sometimes distracting.

 

[hallowmann]

Usually use 1-2 min before the visit to prep the note, I write in full sentences during the visit, but maintain a lot of eye contact and ask related questions or clarification/reflection to demonstrate active listening (and also it allows me to type the summary into the HPI). I do the orders during the visit, and I finish the MSE and A&P 5-10 min after the visit. I usually get more done in the morning in real-time, but I get less efficient as the day goes on and by the afternoon I have a handful of notes to finish, which can take me 30 min or so.

I mainly struggle with time with diagnostics. I similarly finish the majority of the HPI/past history, etc. during the visit (although it often needs to be cleaned up a bit and reorganized), and then I have a lot to do in terms of writing up the formulation, suicide risk assessment, and plan. It usually takes me about 30 min after to do just that, because I like to conceptualize and synthesize everything into the formulation. If its a simple case, might take me much less time, but I honestly don't have a ton of those.

I could be more efficient when I used EPIC, but with the EMRs I'm using now, not so much. The trouble with right now is that I'm doing 2-3 diagnostics a day, so I'm spending 1-2 hrs documenting after the fact just for those. Fortunately, I usually get about that much in admin time, but it doesn't leave me room for being less than efficient.

 

[Marasmus1]

Sorry I can't stand long resident notes. I feel like half the time the information required to inform the plan isn't there, and instead there is this pile of useless boilerplate CYA verbiage describing ten different ways the patient is not suicidal. Then on the off chance that the necessary information actually is there, I have to skim through all the verbiage to find it.

I am guessing somebody must be actively teaching them this because all the trainees do it. I'd like to find out who it is so I can pour glue in their keyboard.

Child psych fellow here. I have been taught that the more the narrative part of the note, the better it is. If i just stick with the facts in the HPI part the attendings dont like my notes. They want narrative. Like mom said this, patient responded that way, then mom did this, then patient did that.... less than 2 paragraphs of HPI is not considered a good note in my program..

 

[tr]

Child psych fellow here. I have been taught that the more the narrative part of the note, the better it is. If i just stick with the facts in the HPI part the attendings dont like my notes. They want narrative. Like mom said this, patient responded that way, then mom did this, then patient did that.... less than 2 paragraphs of HPI is not considered a good note in my program..

Yeah like I said I suspect someone out there likes this and is teaching it. Maybe different in child since self-report is more limited though, and observation of dyadic interaction plays a bigger role? I'm not child trained.

IMO I don't think it's appropriate to put any more personal detail in a psych note than is necessary to support the assessment and plan. What if someone subpoenas your notes as evidence in divorce court? Do you really want all that he-said-she-said in there?

 

[TexasPhysician]

Child psych fellow here. I have been taught that the more the narrative part of the note, the better it is. If i just stick with the facts in the HPI part the attendings dont like my notes. They want narrative. Like mom said this, patient responded that way, then mom did this, then patient did that.... less than 2 paragraphs of HPI is not considered a good note in my program..

This is a common difference between academia and private practice. In pp, you don’t get bonus pay for the notes looking pretty.

 

[Mad Jack]

It really depends on where I'm working. My current outpatient job has the worst EMR I've ever used for charting, largely owing to a complete lack of template standardization. I have to build a note by hand basically every time, and it takes about an hour. Total charting time each day is about 2.5 hours. Meanwhile I have seen private clinics and worked in CMHCs that make charting take less than 60 seconds because everything is checkboxes. My inpatient job suffers from poor templates as well, but I've derived some of my own. New patients take like, 90 minutes to two hours because of the absurd number of minor tasks the institution requires, almost all of which are done on separate tabs in Epic. First follow-up takes 15 minutes to chart, each subsequent takes about 5 due to formatting issues.

 

[clausewitz2]

It really depends on where I'm working. My current outpatient job has the worst EMR I've ever used for charting, largely owing to a complete lack of template standardization. I have to build a note by hand basically every time, and it takes about an hour. Total charting time each day is about 2.5 hours. Meanwhile I have seen private clinics and worked in CMHCs that make charting take less than 60 seconds because everything is checkboxes. My inpatient job suffers from poor templates as well, but I've derived some of my own. New patients take like, 90 minutes to two hours because of the absurd number of minor tasks the institution requires, almost all of which are done on separate tabs in Epic. First follow-up takes 15 minutes to chart, each subsequent takes about 5 due to formatting issues.

This sounds like my personal vision of Hell. That job must be awesome in some other way...right?

 

[ObsequiousAplomb]

Additional things that really support the ability to document during encounter:

- Monitor setup so that it's a glance to the side to look at it, not a full body turn. Also making sure that the monitor doesn't obscure any part of your face or body during the encounter
- not wearing glasses if at all possible during tele visits, that way the patient can't see the EHR reflected in your glasses
- silent keyboard. Makes it much less intrusive if nobody can hear the keys
- silent mouse. The clicks can be deafening at times, and a clickless mouse can mean that even in the same room someone might not know you're using the mouse

Ideally, I try to make the mouse/keyboard just as minimally obvious as a pen/paper in the right hand, obscured by the monitor or whatever else is on the desk.

 

[FlowRate]

It really depends on where I'm working. My current outpatient job has the worst EMR I've ever used for charting, largely owing to a complete lack of template standardization. I have to build a note by hand basically every time, and it takes about an hour. Total charting time each day is about 2.5 hours. Meanwhile I have seen private clinics and worked in CMHCs that make charting take less than 60 seconds because everything is checkboxes. My inpatient job suffers from poor templates as well, but I've derived some of my own. New patients take like, 90 minutes to two hours because of the absurd number of minor tasks the institution requires, almost all of which are done on separate tabs in Epic. First follow-up takes 15 minutes to chart, each subsequent takes about 5 due to formatting issues.

If you literally don't have templates available, I ran into that a few times briefly in med school and residency and would keep a word document template, type everything there then copy paste to the EMR. Not sure if that applies to your situation.

While not nearly as bad as your situation, I feel for the extra epic tabs thing. This is even worse for the therapists than the psychiatrists but my org decided that various parts of the note would actually exist in separate sections in epic that don't allow refreshable smartlinks or reselectable smartlists and they're heavily templated things so you either have to redo the whole thing or selectively edit by hand, either of which takes a while. I'm working on getting us to transition to just having all of the essential documentation in the note rather than in these separate fiddly boxes. We're about half way there but have to try and get some buy in for other teams for moving things like the safety assessment.

 

[mistafab]

Child psych fellow here. I have been taught that the more the narrative part of the note, the better it is. If i just stick with the facts in the HPI part the attendings dont like my notes. They want narrative. Like mom said this, patient responded that way, then mom did this, then patient did that.... less than 2 paragraphs of HPI is not considered a good note in my program..

Wow. This sounds useless and terrible.

May as well have the attendings hire a stenographer. Or better yet, just use a dragon and voice-to-text the entire conversation.

 

[vanfanal]

so how much detail do you guys write for therapy notes, especially in a system where anybody has access.

I’ve gone from writing details to “discussed themes of interpersonal conflict, career aspirations. Discussed concepts of blah blah blah.”

Just wonder because we had paper charts in residency so access was limited. Do you keep the details in your process notes?

Also, what do your initial intake notes look like. It takes me at least 20mins. Ruling things in and out, and explaining context and confounding factors, then discussion of the impression and plan… it all takes a lot of time.

For example: patient reports subjective anxiety but mainly about normal life stressors, specifically school. Some initial insomnia but appeared well rested and not daytime impairments. Functioning okay at school, normal memory and attention. No history of catastrophic thinking or generalised and anxiety. Has good peer group, and no impairment in social situations.

(All other pertinent histories)

Discussed impression and treatment options. Discussed anxiety is a normal part of life and current symptoms do not meet criteria for GAD. Discussed lifestyle changes. Discussed role of medications, not a truly indicated at this time. Discussed role of substance use including THC and etoh. Patient accepts referral to CBT.

Versus

Normal situational anxiety related to life stressors. No significant neruovegetative symptoms. Symptoms not consistent with GAD. No social anxiety. No phobia.

Discussed impression and options.
Patient elects to try CBT.

 

[forchinet121]

so how much detail do you guys write for therapy notes, especially in a system where anybody has access.

I’ve gone from writing details to “discussed themes of interpersonal conflict, career aspirations. Discussed concepts of blah blah blah.”

Just wonder because we had paper charts in residency so access was limited. Do you keep the details in your process notes?

Also, what do your initial intake notes look like. It takes me at least 20mins. Ruling things in and out, and explaining context and confounding factors, then discussion of the impression and plan… it all takes a lot of time.

For example: patient reports subjective anxiety but mainly about normal life stressors, specifically school. Some initial insomnia but appeared well rested and not daytime impairments. Functioning okay at school, normal memory and attention. No history of catastrophic thinking or generalised and anxiety. Has good peer group, and no impairment in social situations.

(All other pertinent histories)

Discussed impression and treatment options. Discussed anxiety is a normal part of life and current symptoms do not meet criteria for GAD. Discussed lifestyle changes. Discussed role of medications, not a truly indicated at this time. Discussed role of substance use including THC and etoh. Patient accepts referral to CBT.

Versus

Normal situational anxiety related to life stressors. No significant neruovegetative symptoms. Symptoms not consistent with GAD. No social anxiety. No phobia.

Discussed impression and options.
Patient elects to try CBT.

My notes are for very short, intake notes take 5-10 minutes, follow up notes take under 3min, I don’t write that much just enough to have basic info, safety assessment and plan. Notes are for insurance billing and malpractice so why spend so much time on the note? Waste of time imo

 

[allantois]

I don’t have the attention span to read long notes..

 

[psychmd03]

My notes are for very short, intake notes take 5-10 minutes, follow up notes take under 3min, I don’t write that much just enough to have basic info, safety assessment and plan. Notes are for insurance billing and malpractice so why spend so much time on the note? Waste of time imo

This is my thought as well so mine go even faster yet. A variety of templates a quick specific Fun quote or two change a few small details done.

 

[tr]

so how much detail do you guys write for therapy notes, especially in a system where anybody has access.

I’ve gone from writing details to “discussed themes of interpersonal conflict, career aspirations. Discussed concepts of blah blah blah.”

I don't put any personal detail in therapy notes either. I just list the general topic and the techniques we used. E.g.,

"CBT session #8
Goal: reduce anxiety

Today we reviewed an interaction with spouse using Role Play and Reverse Role Play. Explored pt's reaction using Socratic Questioning, Examine the Evidence, and Downward Arrow.

Assessments:
GAD7: 12
Evaluation of therapy session: empathy 18, helpfulness 19, satisfaction 8, commitment 8, negative feelings 1, difficulties with questions 0

HW: Practice You-Feel/I-Feel for anxiety -inducing interactions with spouse"

 

[hamstergang]

Notes are for insurance billing and malpractice so why spend so much time on the note? Waste of time imo

Notes are also for reminding yourself next time what went on and for communicating to other doctors who may cover for you or take over care from you.