Reviewing and entering information "as you go" doesn't have to mean "in the room." You review the information with the patient in the room and then, when the encounter is over, you jump on your computer and wrap it up.
Correct. Every visit really takes place in three parts.
The "pre-visit" is after the patient has been roomed by the MA and vital signs entered. I'll look at the chief complaint or figure out what chronic conditions need to be addressed, quickly review any labs or studies that were done beforehand (I've already seen them once before), sketch out a quick "skeleton note" (basically a normal cursory ROS and PE - the stuff I ask and do on everyone), and sometimes even start on the assessment and plan, if it's fairly obvious that something's stable and we're likely to continue our current regimen.
During the visit itself, I'll add a few things to the note, and maybe change something from normal to abnormal if necessary. Sometimes (frequently), the patient brings up new issues, and I'll add those in, as well.
After we're done, as the patient is heading to check out, I'll finish the note (the "post-visit") - usually while standing at the nurses' station - send any prescriptions to the patient's pharmacy, pre-order labs for next time, and sign off the note. At check-out, the patient will receive a printed visit summary (basically, my assessment and plan along with a few other things). This is something we've had to do for CMS Meaningful Use, but it's a good idea nonetheless.
Voila! On to the next patient.
