Tips for Efficient Medical Documentation
Is there a way you can spend quality time with your patients without having to be bogged down by your documentation? Can you actually take a break during lunch time to eat instead of catching up on progress notes and answering messages in your inbox? Take back control of your time in the clinic and enjoy practicing medicine.
A Regular Day in Clinic
You start your day with the goal of staying on schedule and keeping up with your progress notes. It takes more than 10 minutes for your medical assistant (MA) to room and take the patient’s vitals, so you only have 10 minutes left to see your first patient. You spent 15 minutes in the room. Not too bad, you are only five minutes behind. However, you didn’t have time to complete your note. It’s okay, you tell yourself, you will catch up between patients or at lunch time. 
The second patient was a wreck; he didn’t get the medication you prescribed during the last visit. He is symptomatic and his numbers are off the chart. It took you 40 minutes to straighten things out, counsel the patient and coordinate his care. You only had a 20-minute appointment slot, so you are already 25 minutes late to see your third patient. Not too bad, standard waiting time in your doctor’s office. 
You are entering the room to see your third patient and apologize for the delay. You explain it was actually good she got some time to settle down a little bit because her blood pressure was high. The repeat blood pressure is now normal. All good, except you haven’t finished a single note. At least you had time to enter some ICD-10 codes, order some labs and medications. 
You are now just half an hour behind. Your next patient is a depression/anxiety follow-up. Okay, let’s see how it goes. Not too bad, the patient just rambles for half an hour, and you successfully convince the patient not to use Ambien for sleep or Ativan for panic attacks. You are now 40 minutes behind. 
Your next patient is here for his pain meds refill. He has been waiting for a while and already came out the room to ask the MA how much longer it is going to take. Your plan was to taper off his Norco, but you are concerned about the time required for that kind of counseling when you are already an hour behind schedule.
Is there a better way?
Is there a way you can spend quality time with your patients without having to be bogged down by your documentation? Can you actually take a break during lunch time to eat instead of catching up on progress notes and answering messages in your inbox?
Some clinicians start their day a few hours earlier to pre-chart and get ready for the day, but it is easy to forget what the visit was about by the time the patient arrives to the visit. Another option? Huddle with your team to strategize and motivate — but that can only get you so far. Let’s talk about some real-world strategies to finish clinic on time and not have to stay an extra hour or two finishing notes or, worse, having to take some work home.
Real-Time Pre-Charting (RTPC)
RTPC can be done just before seeing your patient. You scan the last note to identify the conditions that you need to follow up on and your MA should capture a good chief complaint from your patient, not just “here for f/u.” That way you get a clear idea of why the patient is in your clinic and what he expects out of the visit and what the agenda should be to meet those expectations.
But, the idea behind RTPC is to save you some time, too. Why not aim to have most of your chart completed before you even see the patient? To achieve this, having templates our using dot phrases is essential. By using dot phrases, you typically can complete a short note in less than a minute.
Even if you are running late, investing a minute or so in RTPC using dot phrases, would give you more time to listen to the patient and have a more meaningful visit. The idea is to be able to just do some minor edits to the note during the visit. As you become more familiar with the content of your dot phrases, you can edit them more quickly.
If you want to take your charting to the next level, you could also pre-input the ICD-10 codes that you think you might address during the visit. If your patient comes complaining of knee pain, you might assume it is knee osteoarthritis and save some time by adding the code. You might end up deleting a code or two at the end of the visit, but it still helps you stay on track.
Another timesaver is to order labs ahead of time. If your diabetic patient will be needing an A1c and microalbumin, order the labs before you enter the room. Why waste precious time with your patient interacting with your computer instead of her? The return on investment is huge. The time it takes you to complete your note after the visit is very manageable.
Completing your note right after the visit is also very important, even if you have to make your next patient wait an extra minute.
Spend a minute finishing your note right after the visit or 10 minutes at the end of the day.
Finishing your note while your recollection of events are still fresh in your mind is much more efficient than trying to do so later during the day. You don’t have to recall if it was the right or the left knee that the patient was complaining about.
There is much art as there is science in the practice of clinical medicine. Taking measures to prepare for your office visits and increase your medical documentation efficiency is essential. As Benjamin Franklin said, “By failing to prepare, you are preparing to fail.”
By Gerardo Guerra Bonilla, MD
Founder/CEO at Chartnote. Physician Innovator, Founder, Best Seller Author. Practicing Hospitalist & Family Medicine. Passionate about empowering physicians with technology to improve efficiency of their workflows and allow them to have meaningful interactions with their patients.
About Chartnote
Chartnote is revolutionizing medical documentation one note at a time by making voice-recognition and thousands of templates available to any clinician. We know first-hand that completing notes while treating patients is time-consuming and an epic challenge. Chartnote was developed as a complementary EHR solution to write your SOAP notes faster. Focus on what matters most. Sign up for a free account: chartnote.com