Writing Notes while in Clinic?

[thisampgoestoeleven]

Greetings, All,

In contrast to another thread, I actually really like clinic, shooting the breeze with my nurses and staff, and taking care of patients and their families. But, the documentation...

I am curious to get other clinical oncologists' thoughts on how (or if) you write notes "in real time" in a busy practice where you are seeing patients every 15 minutes.
My adrenaline is high when seeing umpteen / twenty patients, not to mention fending off emails and phone calls, that I can hardly get myself to sit down and think to write a single progress note. If I can leave clinic having written 2 or 3 notes that is a major feat. For me I use my prog notes as my checklist and so they tend to be moderately detailed, so maybe that is my fault. But I see it as covering myself for future med mal. However I find I'm consistently going home from clinic, missing dinner, tucking the kids in bed, and spending 2-3 hours writing 18 notes. It's not horrible, and thank goodness it's not everyday, but annoying enough, and my SO grumbles when I sneak into bed at 12:40AM.

I really can't bring myself to write a note while in front of a patient in the room. As a patient, I hate it when my PCP does it.

Is this typical? Am I doing it wrong? Any tips for efficiency? I honestly don't find Dragon all that helpful. Because of copy-forward, I'm really hunting for words to highlight and replace to make the note updated. The un-usability of the EHR definitely slows me down.

(As an aside, I can't imagine how community docs do this 5 straight days a week.)

Many thanks,
Jr Attending

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[gutonc]

Where are you in your "junior attending" life?

I'm 9 years in. I have a lot of admin time but my clinic days are bats*** crazy. Today was a light day. I saw 19, 3 new. 2 of the 3 new patients were seen with a fellow rotating in my clinic and both were complicated. I left before 5 and the only 2 notes I haven't finished are the ones for the patients I saw with the fellow.

It took me 5 years or so to get to this point. And there are definitely days where I just say f*** it and leave half a dozen notes open. But those are rare these days.

On a related note, the most recent CMS rules for billing and new E/M codes have definitely improved my life (and increased my billing). The only thing I copy-pasta is my history and exam, the rest is fresh every visit.

I should also point out that my productivity for the last quarter was in the MGMA 90th %ile. It's enough to choke an academic doc half to death, but most of my community/academic colleagues can't/won't keep up with this either.

 

[QuizzicalApe]

Greetings, All,

In contrast to another thread, I actually really like clinic, shooting the breeze with my nurses and staff, and taking care of patients and their families. But, the documentation...

I am curious to get other clinical oncologists' thoughts on how (or if) you write notes "in real time" in a busy practice where you are seeing patients every 15 minutes.
My adrenaline is high when seeing umpteen / twenty patients, not to mention fending off emails and phone calls, that I can hardly get myself to sit down and think to write a single progress note. If I can leave clinic having written 2 or 3 notes that is a major feat. For me I use my prog notes as my checklist and so they tend to be moderately detailed, so maybe that is my fault. But I see it as covering myself for future med mal. However I find I'm consistently going home from clinic, missing dinner, tucking the kids in bed, and spending 2-3 hours writing 18 notes. It's not horrible, and thank goodness it's not everyday, but annoying enough, and my SO grumbles when I sneak into bed at 12:40AM.

I really can't bring myself to write a note while in front of a patient in the room. As a patient, I hate it when my PCP does it.

Is this typical? Am I doing it wrong? Any tips for efficiency? I honestly don't find Dragon all that helpful. Because of copy-forward, I'm really hunting for words to highlight and replace to make the note updated. The un-usability of the EHR definitely slows me down.

(As an aside, I can't imagine how community docs do this 5 straight days a week.)

Many thanks,
Jr Attending

I don't use dragon either. I write notes in between patients while they're being roomed. If I am doing telemedicine, I write the note while I'm talking to the patient. For in person visits, while I don't write full notes notes, I do jot down key facts in the EMR that patients mention so I don't forget when I do write the note (IE my EGD will be on May 10th). I acknowledge what I'm doing and apologize but say I don't want to forget their details for when I write my note later. I've never had anyone be less than understanding about it. I placed orders and write check-out instructions while I'm in room, telling the patient that this is the part of the visit where they watch me do paperwork for a minute but at the same time it stops me from being distracted by something later and forgetting it.

If you acknowledge what you are doing and explain it it generally goes over well.

Also I agree with gutonc, the new E&M guidelines have made notes so much easier to get through. You can cleave away so much junk that was there just to satisfy some billing requirement.

 

[thisampgoestoeleven]

I'm 1 year in. I think writing notes while pts are rooming is no problem. Where I have difficulty / I feel bad is when the next pt is roomed and ready, or the clinic overall is running an hour behind, how to justify spending those 5-10 minutes to write/bill when folks are tapping their feet.

I will say that dragon is helpful for pre writing the HPI on new patients. I will make a floating dictation window and basically read off the referral documents and that comprises the prose of my HPI. Takes a mere 5-10 minutes to comb through 40-60 pages, i'm basically just reading out loud.

 

[gutonc]

I don't use dragon either. I write notes in between patients while they're being roomed. If I am doing telemedicine, I write the note while I'm talking to the patient. For in person visits, while I don't write full notes notes, I do jot down key facts in the EMR that patients mention so I don't forget when I do write the note (IE my EGD will be on May 10th). I acknowledge what I'm doing and apologize but say I don't want to forget their details for when I write my note later. I've never had anyone be less than understanding about it. I placed orders and write check-out instructions while I'm in room, telling the patient that this is the part of the visit where they watch me do paperwork for a minute but at the same time it stops me from being distracted by something later and forgetting it.

If you acknowledge what you are doing and explain it it generally goes over well.

This is usually what I do. I explain what I'm doing on the first visit and normalize it. After that, it's not an issue. And it's not like I spend the entire visit typing.

I'm 1 year in. I think writing notes while pts are rooming is no problem. Where I have difficulty / I feel bad is when the next pt is roomed and ready, or the clinic overall is running an hour behind, how to justify spending those 5-10 minutes to write/bill when folks are tapping their feet.

The only person every tapping their feet waiting in my clinic is me. If we're running behind, it's something outside of my control. I typically see my patients ahead of time and I'm usually done with my morning patients 20-30 minutes early. I had a partner (who has now moved to a fully academic practice) who somehow managed to be an hour behind by her 3rd patient of the day...every single day. I get that at the end of the day if you're seeing 30 patients. But how you do that less than an hour into the clinic day is beyond me.

 

[FinleySt7]

Greetings, All,

In contrast to another thread, I actually really like clinic, shooting the breeze with my nurses and staff, and taking care of patients and their families. But, the documentation...

I am curious to get other clinical oncologists' thoughts on how (or if) you write notes "in real time" in a busy practice where you are seeing patients every 15 minutes.
My adrenaline is high when seeing umpteen / twenty patients, not to mention fending off emails and phone calls, that I can hardly get myself to sit down and think to write a single progress note. If I can leave clinic having written 2 or 3 notes that is a major feat. For me I use my prog notes as my checklist and so they tend to be moderately detailed, so maybe that is my fault. But I see it as covering myself for future med mal. However I find I'm consistently going home from clinic, missing dinner, tucking the kids in bed, and spending 2-3 hours writing 18 notes. It's not horrible, and thank goodness it's not everyday, but annoying enough, and my SO grumbles when I sneak into bed at 12:40AM.

I really can't bring myself to write a note while in front of a patient in the room. As a patient, I hate it when my PCP does it.

Is this typical? Am I doing it wrong? Any tips for efficiency? I honestly don't find Dragon all that helpful. Because of copy-forward, I'm really hunting for words to highlight and replace to make the note updated. The un-usability of the EHR definitely slows me down.

(As an aside, I can't imagine how community docs do this 5 straight days a week.)

Many thanks,
Jr Attending

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