Finding The Most Efficient Way To Finish Patient Charts

Patient documentation has been a major burden for many physicians. The long after-hours of charting brings upon a toll on a physician’s physical and mental well-being, and in turn, potentially affects patient care in a negative way. If you are a physician who is charting at night and in the weekends, this is for you.

If I could just go home earlier with my work done (without changing my job), that would be great. That used to be my wish. I use the word wish because it did not seem possible at that time. It seemed like someone else could do it and it was them, not me.

Until you turn your wish into hope, hope into a glimmer of possibility, it is difficult to envision efficient charting and going home on time will be your reality. That little bit of possibility ignites the flame of belief in you, and that is the first key to finding your way to do your charts faster. If you do not believe you can do it, would you put in your best effort to try?

Be curious and be open to possibilities. Besides being open to thinking that you can be more efficient in patient charting, it is also important to be open to trying different things. If other physicians can do it, so can you. They are the proof of this possible outcome.

Examine your circumstances at work. Are you practicing mostly in-patient or outpatient care, or both? Different circumstances may require different methods to increase efficiency. If you want to work on the in-patient charting, look into the environment. Are you seeing patients in one unit or in multiple units throughout the hospital? Where do you do your charts – is there a central location for documentation or is it convenient for you to use any computer throughout the hospital? What kind of ancillary help do you have? If you are mainly in the out-patient environment, look into the patient flow and the team work with your staff members. Is the exam room set up in a way that is convenient for you to do your chart while talking to the patient?

What are the resources available for you to increase charting efficiency? First, look at yourself. Are you good at typing? Are you able to talk, look at the patient and type simultaneously? Dictation tools – does your office or institution provide you with a dictation program? Utilize your electronic medical record (EMR) program – most EMRs have a built-in function for you to program text expanders or dot phrases, so for content which you discuss with your patient frequently, it saves you time to just type in several keys to have a whole paragraph (or even a page) to appear.

How about a scribe? Someone is typing what you are saying in real time – that seems to be a great way to cut down your charting time. Several years ago, I had this belief that a scribe would help me go home on time, which led me to write up a proposal for the administrator to get our office a scribe. The proposal was approved – by the time that the scribe was hired, I ended up not having to use the scribe and was efficient with my typing and dictation.

Artificial intelligence – that is a hot topic everywhere. AI-powered scribe may be a game changer for you. It is usually an accurate summary of the patient encounter. It is designed for easy use and, unlike a human scribe, there is not much training involved. There are quite a few programs available which are HIPAA compliant. Some EMR programs are incorporating AI technology.

There is more than one way to increase your efficiency in charting. For the optimal results, it is important to believe that you can do it. Stay curious, be open-minded and flexible. There is no one size fits all. If you are working in two or more different locations, you may do things differently according to the environment and resources available. If you think that something may help you, do not be afraid to ask for it. Charting efficiently and going home on time is possible for you!